Tool for Evaluating Root Causes and Contributing Factors

Event report analysis can be conducted at various levels using a number of different approaches. States may analyze individual event reports to hold facilities accountable for serious errors and to better understand and share contributing factors (i.e., communication, safety culture, etc.) so that events can be avoided in the future. States may also aggregate data over time and/or across facilities to assess the patient safety performance of a facility, region, or state. State-level aggregated data can be used to identify institutional factors that may contribute to adverse events, which cannot be identified by an individual facility.  Aggregated data can also enable a state to build a larger database with a greater number of events to enhance analysis of rare events.  This section of the toolbox contains tools that may help states with both kinds of analysis.

The challenges of analysis 
Statistical analyses of event reporting can be problematic. The small number of events reported in most states limits the type of statistical analyses that can be conducted. The number of reported events is not a valid indicator of the incidence of events as the number of opportunities for the event to occur is usually unknown. For instance, the number of morphine overdoses may be captured accurately, but the number of morphine injections given in all the hospitals in the state over a certain time period will probably be elusive. Nonetheless, there are ways to use reported data that, while not yielding epidemiological trends, can enhance our understanding of what causes these events and how they can be reduced.

New York Root Cause Analysis Evaluation Protocol|| New York