Teaching Root Cause Analysis
Teaching Root Cause Analysis
We describe our method of exposing radiology residents to root cause analysis. Our interactive casebased, small-group teaching session uses a flipped classroom approach which allows the session to focus primarily on working through the case in small groups. This methodology can be easily integrated at other institutions.
CASE SUMMARY—WRONG SITE INJECTION A 53-year-old male with chronic foot pain presented for a
fluoroscopically guided steroid injection of his right foot after
having experienced no pain relief following an injection performed in the orthopedic office. After obtaining written
informed consent and performing a time-out, the radiology
fellow and attending radiologist successfully injected 40 mg
of Depomedrol and 0.5% Sensorcaine into the second and
third metatarsophalangeal joints (MTP). After the procedure
was completed, the patient commented that the band-aid was
in a different location compared to the prior procedure. A
review of the requisition showed the order to be “please inject
steroids into the 2nd and 3rd MTT joints.” After realizing
that the wrong joints were injected, an apology was issued
and the correct joints were injected.
ANALYZING THE CASE
One week prior to the 1-hour interactive learning session, a
representative case is distributed to the residents along with
instructions to read two articles explaining the RCA process. This flipped-classroom approach allows the session to
focus primarily on working through the case in small groups
rather than just reviewing the basic concepts. The session starts
with a 15–20 minute review of the five key steps of RCA
as well as the commonly used RCA tools, such as
Ishikawa/fishbone diagrams, Pareto charts, and causal tree maps.
The residents are then divided into five groups of four to five
residents, with each group being instructed to tackle one of
the five major tasks . Typically, accounting for call
responsibilities and offsite rotations, approximately 25 residents attend each session, and each small group comprises five
residents divided at random by the program director facilitators. Ideally, each group is composed of residents across all
four years of training as each resident brings different levels
of expertise and experience to the discussion. As our program
conducts one RCA session annually as part of our broader
curriculum encompassing approximately 10 to 15 lectures directed to quality and safety, we have found attendance to be
excellent. Over the course of the entire residency, each resident has exposure to at least two to three RCAs during their
training.
