Using root cause analysis to improve survival in a liver transplant program

BACKGROUND: With the advent of programs such as the American College of Surgeons-National Surgical Quality Improvement Program, surgical services will be compared with their peers across the United States. At times, many programs will experience lower-than-expected outcomes. During July 1, 1998, to June 30, 2000 our 1-year graft (76.86%, P = 0.23) and patient (80.61%, P = 0.016) survivals after liver transplantation were lower than our expected rates (graft 81.89% and patient 88.3%), according to the U.S. Scientific Registry of Transplant Recipients (SRTR). METHODS: We used aggregate root cause analysis to determine underlying reasons for our patient deaths. Two of our surgeons performed a systematic review of all our center's liver transplant patient deaths from January 1, 1995, to December 31, 2000. Each phase of the transplant process was reviewed. RESULTS: Of 355 patients receiving their first transplant, there were 90 deaths, with 188 root causes identified. The apportionment according to phase of the transplant process was patient selection, 50%; transplant procedure, 17%; donor selection, 15%; post-transplant care, 8%, and psychosocial issues, 10%. Risk reduction action plans were developed, and several important changes made in our care protocol. In April 2004, SRTR data revealed that for patients transplanted between January 1, 2001 and June 30, 2003, our 1-year liver graft survival of 90.73% (P = 0.018) was significantly higher than the national expected rate of 84.48%. Our 1-year patient survival rate of 92.66% (P = 0.285) was higher than the expected rate of 89.29%. CONCLUSIONS: Lower-than-expected outcomes can provide an impetus for improving patient care and raising the quality of a surgical service. Aggregate root cause analysis of adverse events is a valuable method for program improvement.