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Castro, PhD, MPH  \nRCA Advisory Group:  \nMissy Danforth and Jean-Luc Tilly, MPA; The Leapfrog Group Pat Croskerry, PhD MD CCFP FRCP; Dalhousie University Rob El-Kareh, MD MPH MS; University of California, San Diego Carole Hemmalgarn, MS MS; Patients for Patient Safety Ruth Ryan, BSN, MSW; Medical Writer  \nMichael P Tozier, MD; Maine Medical Center Bob Trowbridge, MD; Maine Medical Center  \nJulie Wright, MSN Ed RN; Intermountain Healthcare Laura Zwaan, PhD; Erasmus Medical Center, NL  \nEditor: Christine Holzmueller, MS; Illustrator: Kristen Garcia, Garcia Alfaro LLC  \nWith appreciation for funding from the Gordon and Betty Moore Foundation through a grant to The Leapfrog Group, and support from The Society to Improve Diagnosis in Medicine  \nROOT CAUSE ANALYSIS OF CASES INVOLVING DIAGNOSIS A Handbook for Healthcare Organizations  \nTABLE OF CONTENTS 2  \nEXECUTIVE SUMMARY 3  \nINTRODUCTION 4  \nRECOMMENDED PRACTICES  \nGetting Started 9  \nCase Finding 10  \nIs this a diagnostic error? 13  \nTriaging: Peer review or RCA? 16  \nConvening the RCA Team 17  \nThe RCA process  \nIdentifying Root Causes 19  \nWhere did things go wrong? 20  \nThe fishbone diagram 22  \nClinical reasoning 25  \nCommon cognitive biases 28 Crafting Interventions 30  \nConclusions & Safety 2 34  \nREFERENCES 37  \n“Safety is an emergent property of systems; it does not reside in a person, device or department of an organization or system. Safety cannot be purchased or manufactured; it is not a feature that is separate from the other components of the system   The state of safety in any system is always dynamic; continuous systemic change insures that hazard and its management are constantly changing.” “People continuously create safety.”  \nRichard I Cook. How Complex Systems Fail (1)  \n©Leapfrog Group, 2024  \nEXECUTIVE SUMMARY  \nDiagnostic errors comprise the largest threat to patient safety in healthcare today. Improving the quality and safety of diagnosis will require learning from cases of diagnostic error (Safety 1) and from cases where the diagnostic process works well (Safety 2) .  \nMost healthcare organizations use root cause analysis (RCA) to study safety breakdowns, and there are many comprehensive resources already available on how to conduct these investigations, from IHI, ASHRM, The Joint Commission, and the VA. Unfortunately, none of these are suitable for analyzing cases of diagnostic error (or success); cases involving diagnosis require considering the cognitive aspects of medical decision-making, a critical area that is not adequately addressed by any of the existing manuals.  \nThis RCA Handbook provides up-to-date and authoritative guidance on how the existing approaches to conducting an RCA can be modified to study cases involving diagnosis. There are several differences: In cases involving diagnosis, the investigation should begin immediately after the incident, the clinicians involved should be members of the RCA team, and the review must include consideration of how the clinical reasoning process went astray (or succeeded), in addition to using a human-factors perspective to consider the system-related contextual factors that might have played a role in the incident.  \nThe Handbook presents detailed instructions for conducting RCA’s of cases involving diagnosis:  \n• How to find cases of diagnostic error or success  \n• How to confirm that the case does indeed reflect a diagnostic error  \n• Whether a particular case should be peer reviewed, or go to RCA  \n• Who should be on the RCA team? Clinicians and patients should be involved  \n• How to map where in the diagnostic process problems were encountered  \n• Using fishbone diagrams to consider the 4 major domains relevant to most cases:  \nThe case, the patient, the clinicians, and the context of care  \n• How to evaluate the cognitive aspects of the decisions that were made by considering ","cbCaicitCn9j5eNc","https://ap.wps.com/l/cbCaicitCn9j5eNc","pdf",10353087,138,"English","# Table of Contents\n## Executive Summary\n## Introduction\n## Recommended Practices\n### Getting Started\n### Case Finding\n### Is this a diagnostic error?\n### Triaging: Peer review or RCA?\n### Convening the RCA Team\n### Identifying Root Causes\n### Where did things go wrong?\n### The fishbone diagram\n### Clinical reasoning\n### Common cognitive biases\n### Crafting Interventions\n### Conclusions & Safety\n## References","[{\"question\":\"What problem does the handbook target in patient safety?\",\"answer\":\"It targets diagnostic errors, described as the largest threat to patient safety in healthcare today, and the need to improve the quality and safety of diagnosis through learning from both failures and successes.\"},{\"question\":\"How should an RCA for diagnostic cases differ from a standard system-focused RCA?\",\"answer\":\"The investigation should start immediately after the incident, involve the clinicians participating in the RCA team, and include analysis of how clinical reasoning went astray or succeeded, alongside a human-factors and system-context perspective.\"},{\"question\":\"What topics does the recommended practices section cover?\",\"answer\":\"It covers case finding, confirming whether a case reflects a diagnostic error, deciding between peer review and RCA, convening the RCA team, identifying root causes, mapping where problems occurred, using fishbone diagrams and cognitive bias review, and crafting interventions.\"}]","Root Cause Analysis of Cases Involving Diagnosis - A Handbook for Healthcare Organizations | PDF",348]