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Root Cause Analysis MPM1-gl

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					GP Risk Management Tutorials

   Root Cause Analysis

 Learning and Sharing Good
          Practice

       GERAINT LEWIS-PRIMARY CARE RISK ADVISER
                Objectives

• To increase your understanding of the theory
  & application of (RCA)
• To gain insight into the skills required to
  undertake effective RCA
• To be able to undertake RCA using the tools
  and techniques demonstrated to investigate
  an incident
Root Cause Analysis and patient safety,
        Why is it important ?

Today’s health-care context is highly complex. Care is often
delivered in a pressurized and fast-moving environment, involving a
vast array of technology and, daily, many individual decisions and
judgements by health-care professional staff. In such circumstances
things can and do go wrong. Sometimes unintentional harm comes
to a patient during a clinical
procedure or as a result of a clinical decision. Errors in the process
of care can result in injury. Sometimes the harm that patients
experience is serious and sometimes people die. (World Health
Organisation-World Alliance for Patient Safety)
   The Patient Safety Agenda
Organisation with a Memory (June 2000)
Even after a decision has been taken to conduct some form of
inquiry or investigation, there is often little by way of consistent
support or expertise available to NHS organisations or to inquiry
teams in the conduct of the process

Building a Safer NHS for Patients (2004)
Described the necessary steps to set up the new national system.
These include building expertise in the NHS in root cause analysis

 7 Steps to Patient Safety (2004)
Guidance to local organisations to ensure that the investigation team they
create is proficient in RCA by providing both online and face-to-face
training
             Where does RCA fit in?


• RCA is part of a Safety and Quality process.

• It sits alongside incident reporting, patient safety education
  and training and feeds into an organisation’s Risk
  Management Strategy.

• It supports the organization to learn and develop
        What is Root Cause Analysis?
What is a Root Cause?
• The root or fundamental issue, is the earliest point at which action could have
  been taken that would have reduced the chance of the incident happening.

What is Root Cause Analysis?
• Structured process using recognised analytical methods

• Enables you to ask the questions “How” and “Why” in an objective way to
  reveal all the causal factors that have led to a patient safety incident.

• Should be used to prevent similar incidents happening again, not to apply
  blame.
            Root Cause Analysis
    To be thorough RCA must involve a complete
    review of all possible antecedent events and
    actions
•   Look at human behaviour
•   Look at processes and systems
•   Consider all the key players
•   Need to understand what went wrong, how it
    went wrong and how it could be done
    differently
            Root Cause Analysis
To be credible a root cause analysis must:
• Be closely supported by the leadership of the
  organisation
• Involve those closely associated with the processes
  and systems and the outcomes.
• Be applied consistently and transparently according
  to organisational policy/procedure
• Include consideration of relevant literature ie what is
  best practice? What processes and systems function
  elsewhere?
             Root Cause Analysis

To be effective a root cause analysis must :
• Include development of actions aimed at improving processes
   and systems;
• Ensure there is agreement as to how those improvements will
   be monitored and evaluated
• Be well documented (including all the activity from the point
   of identification to the process of evaluation).
• Engage those involved in the original incident
• Gain the support of those who can make the changes
           Human Error is Inevitable
–   Two approaches to the problem of
    human fallibility exist: the person and
    the system approaches
–   The person approach focuses on the
    errors of individuals, blaming them for
    forgetfulness, inattention, or moral
    weakness
–   The system approach concentrates on
    the conditions under which individuals
    work and tries to build defences to avert
    errors or mitigate their effects
–   High reliability organisations which have
    less than their fair share of accidents
    recognise that human variability is a
    force to harness in averting errors, but
    they work hard to focus that variability
    and are constantly preoccupied with the
    possibility of failure
         Two Views On Human Error
            Old View                   New View
•   Human error is a cause of   • Error is a symptom of
    accidents                     deeper trouble
•   To explain failure, you
                                • To explain failure, look
    must seek human failure
                                  for the system failure
•   Find people’s incorrect
    assessments, wrong          • Explore how actions and
    decisions, bad judgments      assessments made
•   Get rid of ‘bad apples’       sense at time
    replace with new            • Replacing people leaves
    personnel                     problems in place
                     Error Types                                   Violations involve deliberate deviations from
                                                                   some regulated code of practice or procedure,
                                                                   Reason (1993). They occur because people

                                                                   intentionally break the rules.



                                                                                                        Short cuts
                                                                                                               Good
                                                                                                               reason



                                                                   Familiar situation-wrong
                                                                   package
                                    deliberate deviations from a
                                    protocol or code of conduct
                                                                       Persons training insufficient to cope




These errors occur when people do not
have appropriate, or sufficient, information
upon which to base their decisions or plans




                                        Driving to work on your
                                        day of f ! Autopilot!




                                               Professor James Reason
                                               ‘Error Types’
                Group Work 1
Can you think of one instance where you have
made:

1.A Violation
2.A Mistake
3.A lapse
4.A slip
   Human errors occur because of:

       Inattention
       Memory lapse
       Failure to communicate
       Poorly designed equipment
       Exhaustion
       Ignorance
       Noisy working conditions
       A number of other personal and
        environmental factors
           Systems approach


• “The systems approach is not about changing
  the human condition but rather the conditions
  under which humans work”.
                          J. T Reason, 2001
         Process for RCAs
• STEP 1: Agree facts of event

• STEP 2: Establish causality

• STEP 3: Produce Action Plans
 CASE EXAMPLE:
The Jack and Jill story
                     Step 1
Identify what happened and antecedents

•   How far back do you go?
•   Who do you involve/question?
•   How much detail do you need?
•   Where are all your sources of information?
•   How much time do you have?
RCA - Gathering the information

•   Incident report       • Photographs
•   Health records        • Staff rotas
•   Policies              • Risk assessments
•   Equipment&            • Training records
    maintenance records   • Witness accounts
                          • Interviews
•   Audit data
  RCA -Telling the story : Helpful tools
Timeline:
    Tracks chronological chain of events.
    Allows the team to identify information
    gaps as well as problems in the process
    of care delivery.
Time person grid:
    Maps /tracks the movements of people involved
    before, during and after incident.
Flowchart:
    Depicts events sequence in simple, easy to read
    format.
                                           Timeline
Time Line                                  Timetable of events
06.30       Jack and Jill wake up
06.50       No water in tap
07.00       Jack encourages Jill to get out of bed
07.10       Jill finally gets up
07.20       Pail found
07.30       Jack and Jill proceed to walk up the hill
07.50       Pail filled too full
08.00       Handle on pail breaks and Jack stumbles and bangs his head
08.01       Jill also stumbles and falls
08.30       Jack and Jill found by neighbour walking the dog
08.40       999 call to local ambulance service
09.10       Ambulance arrives
09.25       Local accident and emergency department closed due to broken water
            main
09.35       Jack walks off
09.45       Local pharmacy won’t provide vinegar and brown paper
10.30       Jack goes home and goes to bed with a bottle of whisky and a plastic
            bag
16.00       Jack Found dead in bed-aspirated on vomit.
                                     Tabular timeline
Date and Time of Event   6 May, 2008-08.40                                  6 May 2008-09.25



Event                    999 call received from 22 Bucket Lane-patient 1    Paramedic crew arrive at the area but
                         has broken his crown and patient 2 has had a bad   cannot locate patients. Patients finally
                         fall                                               located and taken to local A and E dept
                                                                            which is closed.


Supplementary            Very distressed patients, one with severe head     Local A+E closed due to a broken water
Information              trauma and patient 2 (partner) has cuts and        main. Asked if patients wanted to go to
                         bruises to legs, chest and a suspected twisted     nearest alternate A+E but patients
                         ankle.                                             disappear. Later patient 1 Male found
                                                                            dead in bed aspirated on vomit.




Good Practice            None                                               None

Care/Service Delivery    Failure to fully assess and document health of     Ambulance slow, Local A+E shouldn’t
Problem                  patient                                            have been closed-Disaster recovery plan
                                                                            should have been implemented, Social
                                                                            services should have been informed
                                                                            regarding patient 1
                                Time-person grid
                          If Jack had made it to A+E!!


     Staff               10.05               10.15              10.25
    Senior Nurse A       With patient 1      With patient 3       On break


 Health care Assistant   With patient 1            ?          Nurses coffee room


    Social Worker        With patient 1      With patient 1     With patient 2


         Dr 1                  ?                   ?              On break




What were they doing over a 20 minute period in the busy A+E
Department
   Step 2- Establish causality


•Analysis focuses on systems and processes and the way
individuals interact with them,
•Analysis starts with apparent or primary causes and
progresses to identification of system vulnerabilities (root
causes and contributing factors)
•Analysis repeatedly digs deeper by asking “why” questions
until no additional logical answer can be identified
•Analysis identifies changes that could be made in systems
and processes to reduce the risk of a similar event occurring
         Step 2: Causality
• Determine pertinent areas

• Focus on pertinent areas

• Formulate causal statements
How would you classify the severity of this
case?

Who would you want/expect to investigate
this case?

What is the extent of your investigation?
QUALITATIVE RISK ASSESSMENT MATRIX – LEVEL OF RISK
(Based on the AS/NZS 4360:1999 Risk Management Standard)
              RCA Techniques
• 5 Whys
• Barrier analysis
• Change analysis
• Causal factor tree analysis
• Failure mode and effects analysis
• Ishikawa diagram, also known as the fishbone
  diagram or cause and effect diagram
• Fault tree analysis
   Example of five whys-I’ve just been given a parking ticket! Why ?




                              I have just been given a
                                   parking ticket
             Why ?

 Parked in a 10 minute max
   parking zone and time
                                         Why ?
          expired                                          Held up in a queue at the local
                                                           bakery
                              Why ?

  The till was inoperative                Why ?             Till had not been serviced by
                                                                    manufacturers
                              Why ?
   Bakery had forgotten to
extend maintenance contract                               Root
                                                         Cause
                                                                              Communication
Patient             Task                 Individual            Team
                                                                                 factors
Factors            Factors                 Factors            Factors




   Equipment and              Working                 Organizational    Education and
     resource                condition                and strategic        Training
      factors                 factors                    factors            factors
        NPSA Contributory Factor
              Framework
•   Patient factors
•   Individual (staff) factors
•   Task factors
•   Communication factors
•   Team and social factors
•   Education and training factors
•   Equipment and resource factors
•   Working conditions factors
•   Organisational & strategic factors
     Step 3


The Action Plan
        Key principles of
        solution creation
 Design tasks and processes that minimise
  dependency on short term memory, attention
  span & avoid fatigue
 Simplify task, processes and so on
 Standardise processes & equipment
 Use tools and checklists wisely
 Make it easier to do the right thing!
    Process Redesign Solutions
Make mistakes impossible
– Auto-shut off heating devices
– Circuit breakers
– Ready-to-administer medications
– Write-over protected computer disks

–   Can you think of other mistake-proofing techniques?

Remember redesign means new Risks. Solving a problem in one
  area may create a new problem in another
                     SEA/RCA – REPORT FORMAT

                           WHAT HAPPENED?

 (Including the role of all individuals directly and indirectly involved, the
setting for the event, and any impact or potential impact of the event that
         is relevant to patient care or the conduct of the practice)

                          WHY DID IT HAPPEN?

(Including description and discussion of the main and underlying reasons
              for the event occurring, where this is possible)

                     WHAT HAVE YOU LEARNED?

 (Reflect on significant event and highlight personal and, if appropriate,
                           team-based learning)


                   WHAT CHANGES WILL YOU MAKE?
(What action will be taken, where this is relevant or feasible, ensuring that
 all relevant individuals are involved, how will you monitor the changes)
          Report Preparation
• Cause and effect relationships must be
  clear
• Don’t overstate, understate, or
  emotionalize report. It may show up in
  court.
• Negative descriptors may not be used
  – “poorly”, “inadequate”, “unsafe”, “unreliable”,
    and “complacency” among many others
              RCA Summary

•   Gather the facts.
•   Determine sequence of events.
•   Identify contributing factors.
•   Select root causes.
•   Develop corrective actions & follow-up plan.
And finally…a good RCA is one that …

• Identifies all the contributory causes
• Leads to more robust systems and processes
• Addresses all key emergent issues not just root
  causes
• Shares effective ways to reduce the chances of
  similar mishaps recurring elsewhere within or
  without the organisation and /or shares examples
  of good practice
FEEDBACK AND
  QUESTIONS!

 Thank you for listening!

				
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