Learning Objective #1: Engage in root cause analysis in developing policy on patient safety

Learning Objective #2: Perform qualitative and quantitative data collection through mixed methods

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Introduction: The global focus on the business of caring and patient safety, place an enormous burden on nurses who are with patients 24/7. The fundamental reason for the breakdown of a system in any practice setting has a “root cause”. Root cause analysis is one way of learning the reason(s) for the failure or breakdown of a process (error) in a healthcare system. Purpose: The purpose of this study is to perform a retrospective root cause assessment and analysis of moot health malpractice cases. Our specific aims are to: 1) review moot malpractice cases decided by the Allegheny County Common Pleas Court, 2) classify the sentinel event that led to the malpractice outcome, 3) develop a framework for categorizing contributing and mitigating factors, 4) perform mixed methods analysis, and 5) disseminate findings. Methods: Mixed methods analysis will be used to integrate qualitative and quantitative techniques for data collection and analysis. Five attributes in designing mixed methods studies were considered: 1) rationale for mixing methods, 2) techniques used, 3) priority given to quantitative versus qualitative research, 4) sequential or concurrent implementation, and 5) phase at which the integration occurred. Results: The outcomes, prevention and intervention strategies derived from the cascade of events leading to the malpractice suit are traced through all documents filed in court related to the case. Data elements, significant attributes of qualitatively or quantitatively derived errors and categorizing of contributing or mitigating factors are described. Conclusions: Evidence of meaningful transdisciplinary group during the conception and design of the project gathered at monthly meetings at a service-research collaborative partnership. Analyzing malpractice cases needs to be based on careful and thoughtful planning, design, and evidence. Results of mixed methods data collection and data analyses may be translated globally to hasten the application of evidence based research into practice.