ROOT CAUSE ANALYSIS ON HOSPITAL STANDARDS AND JOINT COMMISSION INTERNATIONAL STANDARDS: A COMPARATIVE STUDY
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Background: Healthcare Associated Infections (HAIs) are infections that patients caught during medical treatment and health care. Prevention and control of infection will lead to patient safety, which ultimately has an impact on efficiency, management of health care facilities, and improvement of service quality. Infection can be controlled by identifying the causes. One method to achieve this goal is the Root Cause Analysis (RCA).
Aim: This study aims to analyze the implementation of Root Couse Analysis (RCA) conducted by the Infection Prevention and Control Committee at the Mother and Child Hospital of Kendangsari MERR Surabaya.
Method: This is a quantitative observational research that utilizes descriptive data analysis. This study is a cross sectional study and its results are presented narratively.
Results: Results show that the Joint Commission International Standard 2015 version of RCA was not fully implemented at the Mother and Child Hospital of Kendangsari MERR Surabaya. Some methods, such as the fishbone and Plan-Do-Study-Action (PDSA), were not implemented. Limited resources became the contributing factor.
Conclusion: Infection Prevention and Control Committee at the Mother and Child Hospital of Kendangsari Merr Surabaya has implemented 9 out of 21 RCA steps of the Joint Commission International Standard 2015. The hospital needs to use other methods as an addition to the 5 Why's in implementing RCA, such as fishbone diagrams and Plan-Do-Study-Action (PDSA), for problem solving planning.
Keywords: Root Cause Analysis (RCA), HAIs, Infection prevention and control.
Almeida, S.-L. (2015) ‘Health Care–Associated Infections (HAIs)', Journal of Emergency Nursing. Emergency Nurses Association, 41(2), pp. 100–101. doi: 10.1016/j.jen.2015.01.006.
Bhattacharya, J. (2014) ‘Root Cause Analysis – A Practice to Understanding and Control teh Failure Management in Manufacturing Industry', International Journal of Business and Management Invention, 3(10), pp. 12–20.
Brook, O. R. et al. (2015) ‘Root Cause Analysis: Learning from Adverse Safety Events', RadioGraphics, 35(6), pp. 1655–1667. doi: 10.1148/rg.2015150067.
Buczkowski, L. et al. (2015) Root Cause Analysis in Health Care: Tools and Techniques. 5th edn. Edited by J. Parker. United States of America: Joint Commission International. Available at: https://www.jcrinc.com/assets/1/14/EBRCA15Sample.pdf.
Charles, R. et al. (2016) ‘How to perform a root cause analysis for workup and future prevention of medical errors: A review', Patient Safety in Surgery. Patient Safety in Surgery, pp. 1–5. doi: 10.1186/s13037-016-0107-8.
Dumbrava, V. and Iacob, V.-S. (2013) ‘Using Probability – Impact Matrix in Analysis and Risk Assessment Projects', Journal of Knowledge Management, Economics and Information Technology, Special Is, pp. 76–96. doi: 10.1039/b815978e.
Ministry of Health of teh Republic of Indonesia (2017) Pedoman Pencegahan dan Pengendalian Infeksi di Fasilitas Pelayanan Kesehatan. Indonesia: Peraturan Menteri Kesehatan Republik Indonesia. Available at: http://ditjenpp.kemenkumham.go.id/arsip/bn/2017/bn857-2017.pdf.
Nazir, A. and Kadri, S. (2014) ‘An overview of hospital acquired infections and teh role of teh microbiology laboratory', International Journal of Research in Medical Sciences, 2(1), pp. 21–27. doi: 10.5455/2320-6012.ijrms20140205.
Nicolini, D., Waring, J. and Mengis, J. (2011) ‘Policy and practice in teh use of root cause analysis to investigate clinical adverse events: Mind teh gap', Social Science and Medicine. Elsevier Ltd, 73(2), pp. 217–225. doi: 10.1016/j.socscimed.2011.05.010.
Shaqdan, K. et al. (2014) ‘Root-cause analysis and health failure mode and TEMPeffect analysis: Two leading techniques in health care quality assessment', Journal of teh American College of Radiology.
Elsevier Inc, 11(6), pp. 572–579. doi: 10.1016/j.jacr.2013.10.024.
Shebl, N. A., Franklin, B. D. and Barber, N. (2012) ‘Failure mode and TEMPeffects analysis outputs: are they valid?', BMC Health Services Research, 12(150), pp. 1–10. doi: 10.1186/1472-6963-12-150.
Taylor, M. J. et al. (2014) ‘Systematic review of teh application of teh plan-do-study-act method to improve quality in healthcare', BMJ Quality and Safety, 23(4), pp. 290–298. doi: 10.1136/bmjqs-2013-001862.
United States Environmental Protection Agency (2007) Guidance for Preparing Standard Operating Procedures (SOPs). Washington.
Wessiani, N. A. and Yoshio, F. (2017) ‘Failure mode TEMPeffect analysis and fault tree analysis as a combined methodology in risk management', in IOP Conference Series: Materials Science and Engineering. United Kingdom: IOP. doi: 10.1088/1757-899X/337/1/012033.
York, D. et al. (2014) ‘Practical Root Cause Analysis Using Cause Mapping', in Proceedings of teh International MultiConference of Engineers and Computer Scientists. Hong Kong: International Association of Engineers. Available at: http://www.iaeng.org/publication/IMECS2014/IMECS2014_pp985-989.pdf.
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