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Implementing Root Cause Analysis and Actions: Lessons Learned from the Journey

Posted By Administration, Tuesday, May 16, 2017
Updated: Monday, May 15, 2017

In a breakout session at the upcoming NPSF Patient Safety Congress, members of the Ochsner Health System team detail their effort to implement RCA2.

by Joanna Carmona

As Jessica Behrhorst, system director of quality and patient safety at Ochsner Health System admits, Root Cause Analysis and Actions (RCA2) seemed like an intimidating process before they started implementation in their 13-hospital health care system with more than 1,000 employed physicians and a non-employed medical staff of over 2,000. However, after taking the time to learn about RCA2 and teach it to their team, the health care staff at Ochsner is a lot more open to talking about the process, which has now been added to their regular toolkit. But the question is: how did they get there?


At this year’s NPSF Patient Safety Congress, Ms. Behrhorst and Richard D. Guthrie, Jr., MD, CPE, chief quality officer at Ochsner Health System, will describe their journey through the implementation of the new Root Cause Analysis and Actions model and what they’ve learned in the process.


“When we started in 2015, we were very aware that we couldn’t do RCA2 in a vacuum—it had to be part of a larger cultural change,” said Ms. Behrhorst. “We could put the pieces into place, but if we didn’t have a culture of reporting or trust from our staff that we were going to do something with those reports, we knew we wouldn’t be successful.”


One of the first successes they saw was a significant increase in the number of RCAs being performed including some RCAs on good catches that they may not have done in the past. For example, the team at Ochsner had seen several events where surgical equipment was coming back with bioburden. The equipment never touched or harmed a patient and was sent to get reprocessed, but staff started reporting it, so they used the sterilization process for the RCA2. The team had found enough risk by using the risk-based prioritization matrix that they thought a change in the process was necessary, allowing them to effect change in an area where a patient could have been harmed. 

Jessica Behrhorst

Richard Guthrie,

chief quality officer,

Ochsner Health System

Jessica Behrhorst

system director

of quality and

patient safety,

Ochsner Health System

Many of the tools Ochsner uses for RCA2 have come directly from the 2015 NPSF report, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Ochsner Health System created three distinct presentations based on the report in order to get the health care team up to speed and on board with the complex processes: one was created for leaders in the RCA2 team, another is specifically for team member briefings, and one holds the electronic version of the tools from the RCA2 report. 

Not only has implementing RCA2 proven to be successful within their own system but it has also become a way to share events and experiences with other facilities. Every month, Ochsner hosts a system quality meeting that includes chief nursing officers from across the system, their vice president of medical affairs, and performance improvement and pharmacy leaders. In that meeting, participants started sharing RCA events and the findings from those RCAs. As a result, teams started learning a lot from the sharing, particularly in instances when they found out that other facilities had faced similar events and could share tools to help mitigate the problem. The lasting effect was helping systems recognize that they are not operating in silos.While some areas of health care may fall into the ultra-safe category, where the goal is to avoid risk altogether, other areas may be categorized by the need to manage or mitigate risk.

In the spirit of not operating in silos, Session 301 will share lessons learned from the two years they have implemented RCA2, so that others may learn from their challenges and successes. 

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Do you have any lessons learned to share from implementing RCA2 in your institution? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Joanna Carmona is communications coordinator at the National Patient Safety Foundation at Institute for Healthcare Improvement. Contact her at

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Tags:  2017 Patient Safety Congress  RCA 

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Creating Structure for Sharing Information and Knowledge in Ambulatory Care: Two Exemplars

Posted By Administration, Thursday, May 11, 2017
Updated: Thursday, May 11, 2017

Breakout sessions at the upcoming NPSF Patient Safety Congress discuss how critical information sharing is to safety improvement work.

by Lorri Zipperer, MA


Communication between individuals to leverage what is known in all types of care environments can be difficult. Whether at the organizational or team level, defined goals, processes and expectations help to shore up what information is shared, how it is delivered, and what is done with it.


Two sessions at the 2017 NPSF Patient Safety Congress in Orlando will provide insights into effective information sharing in ambulatory care. They target two important initiatives that benefited from defined methods of information sharing—organizational learning from adverse events or near misses and patient transitions from the hospital to primary care teams. The speakers will discuss their experiences to highlight value associated with taking the time to build processes to apply information and knowledge in support safe care.


Improvement through sharing lessons learned

PeaceHealth recognized that the work done to improve processes wasn’t reliably assimilated to help their organization learn. “We have learned that robust event investigation requires a system-level structure to triage outpatient safety events,” said Andrea Halliday, MD, patient safety officer, PeaceHealth.“Otherwise, problems are solved on a clinic level and we miss an important opportunity to learn from our events and to spread the lessons learned.”


To help their outpatient clinics design and implement improvement strategies drawn from system-reported adverse events and near misses, PeaceHealth:  

  • Established a leadership team to track and discuss events
  • Launched and supported communication opportunities over time
  • Encouraged accountability through documented improvement action plans
  • Monitored the initiative to track its impact

This structured approach didn’t leave learning to chance. It didn’t assume that sharing was happening. Instead the organization committed to a process that raised awareness of the importance of learning from what goes wrong.

"We have learned that robust event investigation

requires a system-level structure

to triage outpatient safety events.".

—Andrea Halliday, MD


Session 305 will discuss the methods used to enable improvements across the ambulatory care continuum of a large health care system.


Safe patient transition from hospital to the community

Transitions are ripe for communication gaps, missteps, and misunderstandings. Transitions from one environment to another offer extra challenges as the team who knows the patient best can be disconnected from their care due to the changed location. Adding to the complexity, the patients may not always be effectively engaged in the process to confirm that they have the information they need to ensure their safety once outside the hospital (See Horwitz et al. 2013)


Handoff tactics such as standardized information bundles and checklists have been noted to make information sharing more reliable in the hospital and after discharge. Breakout session 505 builds on those successes to highlight an improvement strategy at Iora Health for use as patients enter the primary care management space: transition navigators.


“Our experience has shown that involvement of primary care teams when patients are hospitalized is invaluable,” said Sumair Akhtar, MD, MS, associate medical director, culinary extra clinic, Iora Health. "We understand that in a busy practice, it is nearly impossible for most PCPs to directly engage with inpatient teams on every occasion, therefore, to improve the primary care team's influence and involvement in inpatient care, we have proposed a multidisciplinary model that leverages team nurses and clinically savvy non-clinicians (with solid process and simple tools) to be the liaisons between the patients, caregivers, and inpatient and primary care teams.”


The speakers will discuss how transition navigators help to ensure that communication is clear and concerns are addressed when patients transfer out of the acute care environment. They will share tools and measures that have supported the development of this innovative member of the care team. 


Both these sessions will discuss ways to ensure that information and knowledge sharing wasn’t left to chance. They support the value of resourcing and tending to processes of transferring information to ensure that organizations and care teams are prepared to safely serve patients and families.


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Patient Safety Beyond the Walls of the Hospital is one of six Breakout Tracks featured at the NPSF Congress May 17-19. View more details.

What methods do you employ at your organization to support effective information? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.


Lorri Zipperer, MA, is the principal at Zipperer Project Management in Albuquerque, NM, specializing in knowledge management efforts and bringing multidisciplinary teams together to envision, design, and implement knowledge sharing initiatives. Among her publications, Ms. Zipperer recently served as editor for two texts, Knowledge Management in Healthcare and Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer, both published in 2014, and as a co-editor for the 2016 publication Inside Looking Up, published by The Risk Authority Stanford.

Tags:  2017 Patient Safety Congress  communication  transitions 

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Surveillance Monitoring for All

Posted By Administration, Tuesday, May 9, 2017

Breakout session at the upcoming NPSF Patient Safety Congress details an initiative to institute continuous surveillance monitoring on a large scale.

by Patricia McTiernan, MS

The Joint Commission’s 2012 Sentinel Event Alert #49 on the safe use of opioids in hospitals came as a wake-up call to many clinicians and leaders. Although opioids can be largely safe for many patients, the alert warned of dangerous potential side effects, particularly respiratory depression.

Just a few months after the release of that alert, an event related to respiratory depression and opioid analgesics resulted in a patient’s death at Wake Forest Baptist Medical Center in Winston-Salem, NC. A root cause analysis was conducted, and one of the recommended actions was to use surveillance monitoring of patients receiving opioids. That led to a major initiative resulting in widespread use of surveillance monitoring in multiple facilities.

Kristina Foard RN, MSNEd, SCRN, Nurse Practice Specialist, joined the effort to identify the best system for Wake Forest and assist with the implementation. She and Dr. Robert Weller, physician champion for the surveillance monitoring deployment and response to SE#49 at Wake Forest, were asked to evaluate some of the available bedside monitoring systems that would allow for surveillance monitoring.


Historically, medical/surgical nurses have relied on spot-checking their patients by collecting and recording vital signs every 4 to 8 hours. Of the opioid-related sentinel events reported to TJC between 2004 and 2011, 29% were related to improper monitoring of the patient. As early as 2011, the Anesthesia Patient Safety Foundation was calling for continuous electronic monitoring of oxygenation and ventilation in patients on opioids.

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Once the Wake Forest team had evaluated the options, they began a 20-week pilot program on a neurosurgery unit. Because they wanted to capture as much data as they could during the pilot, they decided that any bedded patient on that unit would be placed on continuous monitoring. At the end of the pilot period, they evaluated the data with the nursing staff and with patient and family input. When they presented the results to their leadership team, the decision was made to deploy surveillance monitoring broadly throughout their institution.
Karen Luse, MSN, Robert Weller, MD, and
Kristina Foard, RN, MSNEd, SCRN, of Wake
Forest Baptist Medical Center. Ms. Luse and
Ms. Foard will present a Breakout Session at the
upcoming NPSF Patient Safety Congress
about their organization's experience
instituting continuous monitoring


“One important lesson we learned by monitoring everyone is that risk stratification is extremely difficult,” said Ms. Foard. “We like to look at comorbidities and whether patients are opioid naïve or opioid tolerant, if they are obese or have Obstructive Sleep Apnea (OSA), because things like that put them at higher risk for opioid induced respiratory depression. But, in fact, many of the interventions triggered by continuous monitoring were not necessarily opioid-related. We also identified cardiovascular events including tachy- or bradydysrhythmias and hypo- or hypertension that we may have failed to identify if we hadn’t been doing surveillance monitoring on all patients.

“We elected then to apply surveillance monitoring as our standard of care. If you got bedded on a unit that had the monitoring, you were placed on monitoring and the provider had to write an order to remove you,” she added.

Some providers have asked for development of risk stratification that would allow for selective rather than surveillance monitoring of all patients, and this continues to be a barrier to overcome, Ms. Foard said. Both physicians and nurses commonly suggest that “young” and “healthy” patients did not need continuous monitoring, but an effective risk score to apply selective monitoring is not yet available.

Another challenge was alarm fatigue. The system cannot do the kind of critical thinking that nurses do, for example, so the team had to take care in setting wide enough parameters that would minimize non-actionable alarms without missing true deterioration events. These parameters were tested and optimized relative to alarm frequency. Ms. Foard and Dr. Weller also collaborated with their Rapid Response team to develop a flow chart to help the nursing staff manage and respond to alerts.

Ms. Foard and her co-presenter will discuss the technical challenges as well as the cultural challenges involved in such an initiative.

“Leadership support and buy-in from managers of the unit is an absolute must,” she said. “Without manager support, you’re not going to get the buy-in from the bedside nurses. Even beyond that, having the executive support for that cultural shift, especially a shift that impacts providers and nursing staff, is critical.”

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Kristina Foard and her co-presenter, Karen Luse, MSN, will talk about this initiative in Breakout Session 304: Surveillance Monitoring on General Care Floors, at the 19th Annual NPSF Patient Safety Congress. See details of the full Congress program.


Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Patricia McTiernan is editor of the P.S. Blog. Contact her at

Tags:  2017 Patient Safety Congress  opioids  respiratory depression 

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