The results are presented first with a case description, illustrated by a timeline of the sentinel event and the subsequent RCA process (Figure 2), and then with a description of three main themes and sub-themes we identified in the data. The first theme, referred to as “the management system,” outlines how the hospital management system manages sentinel events. The second theme, which we named “external and internal assessment,” focuses on how the RCA team perceived the role of “externals” and “internals” in evaluating the incident. Finally, the third theme, “being a team member,” describes how team members experienced carrying out an RCA process.
Case description (The RCA team’s summary from the final report)
A woman giving birth [number of births], identified as a high-risk birth due to known gestational diabetes and a previous cesarean section, is admitted for labor induction at week [weeks of pregnancy]. She receives a birth epidural assessed to have little effect during the birth. A new epidural is placed, but the woman gets high spinal/blockage symptoms after this admission. The anesthesia takes over with subsequent paralysis of the muscles, leading to breathing difficulties and signs of hypoxia. An emergency cesarean alarm is triggered, and the baby is delivered quickly but emerges pale and lifeless. Life-saving treatment is carried out on the baby. The baby’s heart is successfully started; however, the child has symptoms of extensive damage compatible with oxygen deprivation. The treatment ends the next day. The baby is declared dead around 12 hours after birth.
Figure 2. The course of the sentinel event and the subsequent RCA process
Theme: The management system
The term “healthcare management system” encompasses the collection of policies, procedures, and practices that govern the decision-making processes and operations within a healthcare organization. In Norway, the management system is primarily described in the Norwegian RCA guidelines (21) and regulated by different laws and regulations (19, 31, 32). It outlines the requirements for conducting an RCA process, stating that “the hospital’s management system must have procedures in place for assigning the task of initiating an RCA (as shown in the process owner Figure 1). The procedures and descriptions of responsibilities must be well-known throughout the organization” (21). The management system’s activities describe the processes and methods employed to plan, implement, evaluate, and correct the organization (hospital) to ensure compliance with healthcare legislation.
Quality management department’s role in the RCA process
The hospital trust, considered of medium size in Norway and overseeing four hospitals, had experienced several RCAs within a brief period concerning sentinel events during childbirth. Due to the gravity of the situation, the client manager was asked whether the quality department had the necessary resources and methodological expertise to conduct the RCA independently within the clinic. The Chief Quality Officer (CQO) acknowledged that they needed additional methodological expertise to carry out the RCA properly. The quality management department was brought in to provide expertise on the RCA method to ensure a methodical, correct, and professional approach. At the same time, employees working closely with patients were included in the RCA process. This was expected to facilitate knowledge-sharing and keep the process at a system level.
Members of the quality management department reported that their participation in the RCA process led to new insights regarding the importance for healthcare personnel of adequate rest, the need for more education, and the need to refresh the skills of experienced healthcare workers. They stated that RCA was performed on the most sentinel event in the hospitals, and it was vital that the management took responsibility by carrying out an RCA process when a sentinel event occurred. The CQO worked purposefully to introduce and implement the RCA methodology in the organization and stated that RCA had improved its foundation over the past years. However, the CQO also expressed concern about the low number of RCAs conducted in the organization. “I have sometimes wondered why we carry out as few RCAs as we do. I believe that there are several incidents that we should have investigated, and I am not sure whether it is from the management’s side; it may well be that there is skepticism from employees or a lack of knowledge and understanding when serious things happen and that there is a need for a systematic review to learn.” It was pointed out that they previously had insufficient tools to promote learning after a sentinel event and that RCA was not integrated into everyday thinking. Recognizing the significant learning value of sentinel events and the importance of conducting systematic reviews did not occur naturally. The quality management department realized they needed more general knowledge of the methodology to achieve psychological security in the organization. They pointed out that the current management system was not designed adequately to care for employees after a crisis and that RCA initiation could be an additional psychological burden. They also recognized the need for better follow-up of employees after an RCA process.
The quality management department played an active role in implementing national quality strategies and quality improvement requirements within the organization. However, there were different opinions within the organization on how the quality management department works with quality improvement. The quality management department had experienced resistance from some employees. Some employees were given feedback that they needed to better understand the quality management department’s role. In contrast, those who collaborated with them gained knowledge concerning their support function within the organization and quality improvement. The department appointed a contact person for each clinic to improve collaboration and communicate information about quality improvement tasks. However, some employees perceived the department as an ordering unit rather than a facilitator due to role confusion.
The CQO considered the quality management department a significant asset in implementing the RCA method. Conducting an RCA process was very resource-intensive for the departments involved, and it took work resources from everyday clinical life. It was pointed out that it was not easy for a clinic to carry out an RCA without support from the quality management department. The RCA methodology was considered challenging to implement correctly and not sustainable in the long run. There was a clear rationale for considering RCA unsustainable to carry out following all undesirable events. Therefore, a shortened version of the RCA process was needed, and the team requested national guidelines to support this challenge.
Scattered documentation
The medical experts in the RCA team pointed out that finding all the necessary documentation related to the incident was challenging because the documentation was scattered across different systems and platforms. Despite having ample time to locate the documentation before the RCA team meeting, the medical experts found it challenging to gather the necessary information. This also posed problems for daily clinical follow-up, as information could be missed due to the scattered documentation. “The documentation was spread over many different platforms - so it was difficult to find, which is unfortunate! Both regarding inspections and everyday clinical life where information may be missed.” Furthermore, those outside the organization had difficulty understanding the logic behind each medical journal’s tradition and culture for documentation practices. Therefore, it was considered important to put together an overarching RCA team that works daily with the various work processes and could understand the whole process. The analysis team discovered considerable variation in documentation practices within the organization, making comparing documentation practices in different fields difficult. This variation could potentially threaten patient safety and heighten the need for standardization.
Theme: External and internal assessment
This theme focuses on how the RCA team viewed the role of “externals” and “internals” in assessing the incident. “Externals” refers to entities such as the police or external medical experts from other hospitals involved in the RCA process. They are often perceived as more neutral and impartial, which can benefit a particular analysis. The document analysis revealed that the Norwegian guidelines only partially describe the role of externals. The guidelines require that the analysis team must be multidisciplinary, that all professional groups and subject areas affected by the analysis must be represented, that a physician must be part of the analysis team, and that it is essential to include people who can add an “outside perspective” (21). The guidelines indicate that an inappropriate size or composition may omit critical perspectives and impair the report’s quality and legitimacy.
Composition of the RCA team
It emerged in the interviews that the RCA team was satisfied with the composition of the team. The RCA leader (QCO) decides the team composition in collaboration with the analysis team members and the organization managers. The RCA team comprised six members (as shown in Table 2); half of these were quality management department employees, while the other half consisted of medical experts from various departments. The team’s composition represented different aspects of the sentinel event. However, the team recognized that involving other professional groups, especially medical experts without close involvement in the incident, would have been beneficial. The “external- in-house” medical expert pointed out that other professionals, such as midwives, could have provided critical perspectives: “It might have been more appropriate to include other professional groups, such as midwives, to represent a more holistic composition of different professional groups.” The team members emphasized that working together during the process was seen as constructive, and they were able to come to a consensus.
The management department employees found the process challenging because team members had varying levels of experience with applying RCA. The same employees had participated in national training in the methodology and had conducted multiple analyses within the organization. All medical experts were familiar with the method through previous incidents in their clinics, but this was their first time carrying out a complete RCA process. The team members expressed that employees’ varying levels of experience with the RCA methodology could pose challenges in identifying root causes. Some team members suggested that increasing familiarity with the RCA method would be beneficial for fully understanding the RCA process within the organization. The team acknowledged that variations in experience with the RCA method could affect the quality of recommendations.
Police work interrupting the RCA process
Physicians working in Norwegian healthcare organizations are required to report to the police if an unnatural death is suspected (33). The purpose of this requirement is to inform the authorities that a death has occurred, and an investigation can be initiated if the death appears unnatural. In the RCA team’s mandate, one of the issues was to investigate whether the clinic had appropriate routines for notifying the police in such cases. However, due to internal disagreements, the sentinel event was reported to the police belatedly, leading to a delay in the RCA process. The National Criminal Investigation Service (NCIS) investigated the case with local police to provide specialist expert support. This delayed the interview process in the RCA, as the police and NCIS had to conduct their interrogations before the actual analysis could be initiated.
Several members of the RCA team describe the police’s involvement in the case as disruptive to the internal RCA process. The police also had a very different approach from the RCA team and were perceived as brusque, foreign, and suspicious. “At first, they stepped in, and they were a little brusque, and they came in here and acted strange. They were rough, perhaps because they are used to communicating with people with something to hide!” Some employees felt that the incident was perceived as more serious when the police got involved. The police had turned up at the hospital for a crime scene investigation without reporting in advance. They expected this would be hidden from employees if evidence was tampered with. “Now we are standing outside - can you come and lock us in? Do not tell anyone we are here. In other words, so that they hide something before we come up.” The police then went in and seized evidence inside the crime scene.
One of the medical experts who had worked in other parts of the country gave feedback that it was common practice to report to the police in other healthcare organizations and noted that this element was handled entirely differently in this organization. The RCA team concluded that their organization had no culture and little knowledge and practice of reporting unnatural deaths to the police, which highlighted the need to work on implementation at both the clinic and organization levels.
Using colleagues to provide external medical expertise is seen as challenging for the process and the participants
In the RCA team’s mandate, it was requested by the process owner that a representative of the anesthetists should be part of the analysis team. The RCA team decided to extend this to include all specialist fields involved in the sentinel event. Previous RCA teams had brought medical expertise from outside the organization to offer an external perspective. The challenge in this RCA was that none of the other three hospitals in the organization had a neonatal ward and the expertise this provides. The RCA leader discussed with respective managers whether external medical expertise should be brought in. However, for this RCA, the decision was made to bring medical expertise from within the organization. They acknowledged that obtaining professional knowledge from within the hospital trust was not optimal, as other physicians could consider this decision in the organization as a mistake. At the same time, it was concluded by the RCA leader and the management that they could make use of medical experts who were not directly involved in the sentinel event. Therefore, they weighed the advantages and disadvantages and considered it prudent to use internal medical expertise in the RCA team. It was emphasized that the decision had been made because this was not an external inspection. They believed they had made the right decision by ensuring that the “external in-house” member had not been directly involved in the sentinel event.
RCA team members disagreed about using internal medical expertise, especially regarding colleagues considered “second victims” in the incident. The “external in-house” medical expertise pointed out that external medical specialists could provide a new perspective and make it easier to identify negative work patterns. Spending a long time in the same environment can lead one to become unaware of work habits. Team members suggested that the validity of this RCA could be improved by including external medical expertise and seeking expertise from outside their organization. Evaluating one's colleagues in a relatively small environment was considered unconstructive in the implementation itself. The “external in-house” medical expert expressed that it would be emotionally challenging for the other members to evaluate the actions of their colleagues in the severe event. “I believe I was deeply emotionally detached when it came to those involved, their emotions, and everything related. My presence was primarily focused on the medical aspect of it.” The “external in-house” expert pointed out that internal medical experts should receive support and recognition for their work in the implementation. Still, a consequence could be that internal medical expertise could be affected by the emotional involvement of their colleagues.
The quality management department acknowledged that they had received feedback from their employees in the past that it was challenging to evaluate colleagues while also carrying out an RCA. “It is tough to evaluate colleagues in the way that we do. It is a heavy burden for those in the situations, also in the time afterward, because there are tough assessments and things that happen in ‘a blink of a moment’ that are analyzed thoroughly. It is demanding to be a colleague afterward. Because it hurts, it is a defeat. You have been involved in something challenging, and then it must be assessed afterward, and it is easier if you do not have a relationship afterward.” They pointed out that assessing a situation was easier when there was no prior relationship with those involved.
Theme: Being an RCA team member
The Norwegian RCA guidelines explicitly stipulate that “team members must strive to work neutrally with no other interests than increasing patient safety” (21). This theme is presented with detailed depictions of team members’ experience with the RCA process and the self-awareness they developed during its implementation.
Role challenges
The quality management department remarked that it was challenging for managers to understand the methodology or familiarize themselves well enough with it. They emphasized the need for increased communication with managers to ensure they understand the RCA process, their role, and their responsibility for employee follow-up after a sentinel event. One team member coordinated with the police and found it challenging to reassure healthcare staff involved in the RCA process while gathering information for the police and acting as a liaison within the organization. Having two different roles could confuse the purpose of the RCA, leading to insecurity among employees. The team members noted that employees might fear that the RCA could result in disciplinary sanctions and stressed the need to clarify their role as internal investigators. They acknowledged that employees and managers might struggle to distinguish between these roles and emphasized that it was crucial to separate external supervision from the internal investigation. However, it was difficult to determine how employees perceived these roles. For this reason, they emphasized the importance of informing employees about the two distinct roles and clarified this explicitly during interviews.
Ambivalence about being an RCA team member
The roles and motivations of the RCA team members were diverse and complex, with some expressing ambivalence about their participation. On the one hand, they felt a sense of obligation towards the families who had experienced a loss and their colleagues who were also impacted. “I think we owe it to those who have experienced losing their child, as well as health personnel who have experienced this.” They valued the educational aspect of the process and appreciated the chance to work with other experts and learn from resource personnel within the organization. They believed that carefully examining sentinel events, particularly those with significant consequences, was critical. Nonetheless, they found it challenging to scrutinize their colleagues, especially when they discovered mistakes. Some members initially hesitated to participate but felt compelled because the professional pool was too small to make it practical to choose other team members. Some medical experts agreed to join the RCA because they were confident that they would not uncover errors made by their colleagues.
The RCA process was deemed arduous and time-consuming, taking valuable time from team members' already hectic clinical work and leading to heightened stress levels. It also meant sacrificing holidays and leisure time. Performing an RCA was equivalent to taking on additional work on top of the demands already placed on clinicians. This required downgrading or delegating clinical work to others, which was challenging in an already stressful work environment. Previous RCA processes in the organization had indicated that healthcare personnel should have acted differently by adhering to best practices. The members of the quality management department faced challenges when the RCA process revealed that healthcare personnel had made mistakes. Even when the RCA process showed that health personnel had worked under suboptimal conditions, it was difficult for the RCA team members to reconcile their emotions when they realized their colleagues had not performed their duties correctly. Despite this, all RCA team members showed engagement and held positive discussions during the analysis process. However, reading about what had happened to the child and mother in medical journals and interviewing second victims was a demanding and painful experience. Some in the team found this case burdensome and challenging, especially those with close colleagues in the clinic who had dealt with the severe event. Although some team members found the process exciting and instructive, they did not want it to cause additional stress for their colleagues. Medical experts found it exciting to delve deeply into the literature related to the incident and the procedures involved. However, they also expressed that the process was emotionally straining and was not adequately followed up.