How do we make – and keep – our military medical treatment facilities safer?

Facilitated by Air Force Lt. Col. (Dr.) Renée Matos, assistant dean of Quality Improvement and Patient Safety at San Antonio Uniformed Services Health Education Consortium, the RCA W3 course was developed to ensure and improve quality care and reduce negative outcomes at MTFs. COVID-19 pandemic restrictions led to an expanded virtual format this year with an unexpected, positive outcome - even greater participation.

"Medical errors impact healthcare safety, quality, costs and the overall well-being of our healthcare team members. When patient safety events occur, all of those things are affected, including how team members feel about that event," said Matos. "The idea is to give the medical system an objective way to look at those events so that they can prevent them from happening in the future."

Borrowing lessons from other industries, a root cause analysis (RCA) is considered the health care industry's best method to move away from focusing on human error (often termed "blame and shame") and move toward focusing on systemic issues or oversights that can lead to error, Matos explained. The latter approach also results in creating a more transparent environment across the organization in which individuals feel safer to participate in the identification of potential sources of error.

At its base, an RCA is taking a patient safety event or mishap, looking at it from all angles and figuring out the root, or main, cause of the event or where it originated.

'The W3' in the course title stands for:

• What happened?
• Why did it happen?
• What are you going to do about it?

The general idea, Matos said, is to avoid the tendency to blame individuals. While instances of overt negligence do occur and should be appropriately addressed, they are rare. The vast majority of medical errors are due to systemic problems.

For health care workers, placing blame on individuals can lead to burnout, low morale, less transparency, and the potential for more errors in the future.

"We understand that humans are fallible, and we make mistakes. We can't expect humans to be perfect, but what we can do is generate a list of recommended actions which are not targeted at the one person who made a mistake," said Matos. "The idea is to address the system and make the system stronger."

Matos explained that the idea behind an RCA is to develop strong corrective action plans.

"How do you get to the root cause, where you're not saying a person failed to do something but asking why they failed to do it," she said.

For recipients of military healthcare, this ultimately results in making MTFs safer by preventing further adverse events. The RCA W3 course, now in its third iteration, was developed with health care workers often-busy schedule in mind.

"Most root cause analysis courses last a full week and are less likely to be attended by those who need them most, the busy clinicians." said Matos. "To do the job right, an RCA team needs knowledgeable clinicians on board and ready."