Root Cause Analysis Steps in a Root Cause Analysis: Identify the event (overdose) and gather additional information [Columns A & B]; Identify contributory factors [Column C]; Describe the contributory factors on a timeline (0 12 months [Column C]; – Identify root causes by asking 5 “Whys”; Design changes to eliminate root causes; Implement and evaluate change. Identify Substances Directly Identify Additional Information Identify Contributory Factors Contributing to Overdose Prescription drug use: Identify the event (overdose) and gather Identify Contributory Factors: Medical mishap (Rx drugs); information: Lack of education(prescribers, patients, payers, etc); Rx drugs in combination with other Demographic Information: Non-adherence (Rx drugs); substances (alcohol, benzodiazepines, Age; Dose escalation; heroin); Gender; Polysubstance use; Misuse (Rx drugs). Race; Polypharmacy use; Marital status; Pain(physical, psychosocial); Illicit Drug Use: Education level; Desire to get high; Illicit Use of Rx opioids (diversion); Employment status; Desire to avoid withdrawal; Heroin; Military/veteran status; Medical comorbidities; Fentanyl. Insurance status (MA, private insurance). Mental health comorbidities; Location of Death (geography, type); Trauma; Combination Use: Location of residence; SUD history; Cocaine; Benzodiazepines; Circumstances of death (alone, with people, Previous overdose (non-fatal); Alcohol; etc); Criminal Justice System intercepts; CNS depressants; Did decedent access any of the following one Mandatory abstinence (incarceration, treatment year prior to death (# of times): programs); Other substances. Mental health treatment; Treatment availability (lack or inadequate); SUD treatment; Naloxone availability (lack). CJ system (jail, prison, etc); Describe what happened (timelines): ED’s. Material found at scene of death; SUD History; How long decedent was deceased before discovery; Dual Diagnosis (MH/SUD). Was naloxone rescue attempted?
Root Cause Analysis Steps in a Root Cause Analysis: Identify the event (overdose) and gather additional information [Columns A & B]; Identify contributory factors [Column C]; Describe the contributory factors on a timeline (0 – 12 months [Column C]; Identify root causes by asking 5 “Whys”; Design changes to eliminate root causes; Implement and evaluate change. Identify Substances Directly Contributing to Overdose Identify Additional Information Identify Contributory Factors Prescription drug use: Medical mishap (Rx drugs); Rx drugs in combination with other substances (alcohol, benzodiazepines, heroin); Misuse (Rx drugs). Illicit Drug Use: Illicit Use of Rx opioids (diversion); Heroin; Fentanyl. Combination Use: Cocaine; Benzodiazepines; Alcohol; CNS depressants; Other substances. Identify the event (overdose) and gather information: Demographic Information: Age; Gender; Race; Marital status; Education level; Employment status; Military/veteran status; Insurance status (MA, private insurance). Location of Death (geography, type); Location of residence; Circumstances of death (alone, with people, etc); Did decedent access any of the following one year prior to death (# of times): Mental health treatment; SUD treatment; CJ system (jail, prison, etc); ED’s. SUD History; Dual Diagnosis (MH/SUD). Identify Contributory Factors: Lack of education(prescribers, patients, payers, etc); Non-adherence (Rx drugs); Dose escalation; Polysubstance use; Polypharmacy use; Pain(physical, psychosocial); Desire to get high; Desire to avoid withdrawal; Medical comorbidities; Mental health comorbidities; Trauma; SUD history; Previous overdose (non-fatal); Criminal Justice System intercepts; Mandatory abstinence (incarceration, treatment programs); Treatment availability (lack or inadequate); Naloxone availability (lack). Describe what happened (timelines): Material found at scene of death; How long decedent was deceased before discovery; Was naloxone rescue attempted?
Root-Cause-Analysis_table_20160707_v3-0.docx