R36 -ANR- Root cause analysis by klutzfu47

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									                         TRUST POLICY

                MIDDLESBROUGH PRIMARY CARE TRUST
                              POLICY REF: R36


              PROCEDURE FOR THE ROOT CAUSE ANALYSIS OF
                      ACCIDENTS AND INCIDENTS



                                      This document outlines the Trusts Policy on the
SUMMARY                               Procedure for the Root Cause Analysis of
                                      Accidents and Incidents
APPROVING COMMITTEE(S) AND DATE       JSCC 30/09/04, Risk, Health& Safety Committee
                                      06/10/04, HCGC 28/10/04
                                      Adopted But Not Reviewed by the PCT
AUTHOR(S) / FURTHER INFORMATION       TNEY Trust / Risk Manager MPCT
LEAD DIRECTOR                         Director of Performance and Quality Improvement
                                      All Middlesbrough PCT Staff & Primary Care
APPLIES TO
VERSION                               1.0
STATUS (Final / Draft)
                                      FINAL (Adopted But Not Reviewed by the PCT)
THIS DOCUMENT REPLACES                Nil, New Policy
RELATED DOCUMENTS                     Incident Reporting Policy
DISTRIBUTION                          All Policy File Holders, Intranet
REVIEW DUE DATE                       Aug 2005




        ISSUED BY:

                         Chief Executive

        ISSUE DATE:      April 2005
                                                                               02/04
      PROCEDURE FOR THE ROOT CAUSE ANALYSIS OF
              ACCIDENTS AND INCIDENTS

1.ROOT CAUSE ANALYSIS FOR SAFETY RELATED INCIDENTS

The procedure can be applied to both Clinical and Non Clinical adverse
events. The procedure details the involvement of and the actions to be taken
by the investigation person/team, so that the Direct, Contributory and Root
Causes Association with the incident can be identified and recorded. The
information obtained can then be analysed and common causes and trends
highlighted. Appropriate preventative action can then be taken to avoid
reoccurrence.

2. DEFINITIONS

Direct Causes:
Direct cause is defined as the immediate cause(s) that triggered the incident

Contributory Cause:
Contributory cause is defined as that cause which contributes to the
occurrence of the incident, but which by itself would not have caused the
occurrence.

Root Cause
Root cause in defined as the underlying cause(s) to which the incident could
be attributed and if corrected would prevent a reoccurrence.

3.CRITERIA FOR UNDERTAKING A ROOT CAUSE ANALYSIS

The criteria are given in more detail in related policies and procedures via:
   • The Procedure for Reporting and Recording Accidents and Incidents at
       work.
   • The Incident Reporting Policy

MPCT Policy and Procedure requires the risk rating of all clinical and non
clinical incidents.
    • Any incident that is graded as Red (High) or Yellow (Moderate) must
        be investigated by root cause analysis.
    • Any incident graded as Green (Low) must by analysed by root cause
        analysis if the incident statistics indicate that the particular incident type
        is recurrent.

4. PROCEDURES FOR UNDERTAKING A ROOT CAUSE ANALYSIS

The root cause analysis can be carried out by e.g. the Risk Manager, the
Directorate Manager, the Head Of Service, Departmental Manager, or a team.
It is considered best if a team approach is used. The team must include a
member of Management at a level determined by Table 1. The team ideally
would include the Head of Healthcare Governance, the Head of Clinical
Governance or Deputy, the Ward/Departmental/Unit Manager and any other
persons with first hand knowledge of the event or with specialist knowledge. It
is not expected that the team would normally comprise more than five
members.

The team must contain at least one person who has been trained in root
cause analysis.

The purpose of the investigation is to identify the Direct, Contributory and
especially the Root causes of the incident, and recommend remedial actions.

It is not proposed in this procedure to undertake a detailed explanation of root
cause analysis. However, root cause analysis would normally include the
following processes
     • Identify the incident to be investigated
     • Form the investigation team
     • Preserve direct evidence from the scene
     • Chart the event with current knowledge
     • Gather documentary and other evidence
     • Devise the chart
     • Arrange and carry out interviews
     • Revise the chart
     • Identify casual factors
     • Analyse casual factors
     • Decide on and cost the options for improvement
     • Provide a report
     • Ensure implementation plans, phased necessary

5. IDENTIFICATION AND CLASSIFICATION OF CAUSES

Was the identified problem due to:

Natural disasters or criminal activity

Equipment failure
      Expected failure
       • Design Specifications
       • Specifications have potential for improvement
       • Design not to specification
       • Work/equipment interface not considered
       • Design suitability
       • New equipment not up to standard
       • Hazard analysis
      Equipment/part defective
           • Purchasing
           • Handling
           • Storage
           • Quality assessment
           • Manufacturing defect
        Planned Preventative Maintenance (PPM)
           • PPM
           • No PPM

        Repeated Failures
          • Management System
          • Corrective Action

Performance Difficulty

        Individual Performance
           • Excessive tiredness, unwell, upset, bored, distracted,
               overwhelmed
           • No written procedure
           • Written procedure not used
           • Made a mistake using procedure
           • Equipment alarms tuned down or off
           • Not trained to carry out the task and understand the equipment
           • Work environment not conducive to safe practice e.g. dark,
               hot, humid etc
           • Did task involve repetitive motion, uncomfortable positions,
               vibration, or manual handling?

        Team performance
           • Was there a problem with verbal communication or shift
             change over?
           • Were there language difficulties between parties?
           • Was there confusion in the team between who did what and
             when?
           • Was time available to explain procedures/risks to family/client?
           • Did failure of communication between departments: other
             organisations etc play a part?
           • Did a failure in the case notes contribute?

        Management systems
          • Was there pressure to perform the task in a hurry or to use
             shortcuts?
          • Had management been warned of the problems before
          • Were the policies, procedures or admin control not used,
             missing or in need of improvement.
          • Was there a failure in the provision of tests and results
          • Would an independent audit have caught the problem

        Procedures
           • Not used or followed
           •   Wrong
           •   Followed incorrectly
           •

        Training
           • No training
           • Training outcome has PFI

        Communication
          • Non existent or untimely
          • Handover was PFI
          • Misunderstood verbal communication

        Work Direction
          • Preparation
          • Selection of worker
          • Supervision during work

        Quality Control
          • No inspection
          • Assessment tool (PFI)

        Management Systems
          • Supervision
          • Remedial action
          • Policies (PFI)
          • Policies not used

        Human Engineering
          • Man/Machine interface
          • Work environment
          • Complex system
          • Error identification

6.ACTION PLAN AND REMEDIAL PROGRAMME

The root cause analysis will produce:
   • A range or options or reduce the potential residual risk of the incident
      recurring again
   • A range of costs and timescales associated with the above options

The MPCT must determine to which level the residual risk is produced. The
authority to determine the level of residual risk lies with the grade of
Management as determined by table 2.
                                Table 1

                  Managerial Authority to Act on Risks


            Ward       Dept.  Directorate   Clinical    CEO and     Trust
           Manager    Manager Manager       Director   Executives   Board


Major
Incident


High                                                                 X

Moderate                                                   x         X

Low                                            x           x         X

Very Low                           x           x           x         X



                                Table 2

  Managerial Authority for Deciding on Acceptable Levels of Risk


            Ward       Dept.  Directorate   Clinical    CEO and     Trust
           Manager    Manager Manager       Director   Executives   Board


High          x          x

Moderate      x

Low

Very Low
Appendix 1

                              Incident Review

Incident form reference number……………………………………………………

Date of incident…………………………..Location………………………………..

Name of reviewer………………………...Date/time of Review………………….

Investigation team……………………………………………………………………

Summarise the details of the event below and attach any relevant
statement/reports.

a) STATE THE NATURE OF THE ADVERSE EVENT




b) RELEVANT BACKGROUND INFORMATION




c) CONTRIBUTING FACTORS




d) PERSONNEL INVOLVED (include names and grade of staff)




e) IMMEDIATE ACTION TAKEN (at time of the event)




f) SUBSEQUENT ACTION TAKEN (interview, statement, etc)




g) COMMUNICATION AND DOCUMENTATION (parents, staff, case notes,
etc)
Appendix 2
                                  Analysis of Event

To be completed for all HIGH RISK and MODERATE RISK incidents only

A robust and systematic analysis of an incident will help to clarify exactly what
happened and why and event occurred. Having identified the problems an action
plan can be implemented which will help to minimise the likelihood of its
reoccurrence.

Use the checklist below to summarise the specific factors that led to the incident:

This checklist is to highlight the basic causes of the incident resulting from a
formal root cause analysis. It is not a substitute to undertaking a formal root
cause analysis.


POLICIES/PROCEDURES                      Not available
                                         Not clear
                                         Not updated


TRAINING                                 Not available
                                         Not attended
                                         Inadequate


COMMUNICATION                            No/inadequate verbal communication
                                         No/inadequate written communication
                                         Late communication


WORK ENVIRONMENT                         Medical staffing issue (numbers/experience)
                                         Nursing staffing issue (numbers/experience
                                         Inappropriate supervision of junior staff
                                         High activity levels
                                         Equipment failure


HUMAN FACTORS                            Procedures/Policies
                                         Individular error
                                         Tiredness
                                         Personal health problem


NO IDENTIFIABLE FACTOR
Appendix 3
                                    Action Plan

To be completed for all incident, please tick one or more boxes

       Teaching sessions (give details below)
       Informal discussion with individuals (give details below)
       Audit (give details below)
       Joint review with/by another directorate (attach summary)
       Other………………………………………………………

        Action to be taken     Individual      Action       DATE       Residual
                              Responsible     Complete                  Risk



  1

  2

  3

  4

  5

  6




Investigation Complete Y/N          Ongoing Y/N          On Hold Y/N

Reportable to the authorities Y/N

Signature of investigator……………………………………….Date ……………………….

Signature of Directorate/……………………………………….Date……………………….
Departmental Manager


This form should now be given to the Risk Manager



Entered into database (date and sign)………………………………………………………

								
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