Transcript Root Cause Analysis - Public Health Wales

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
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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
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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
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Old View
Human error is a cause of
accidents
To explain failure, you
must seek human failure
Find people’s incorrect
assessments, wrong
decisions, bad judgments
Get rid of ‘bad apples’
replace with new
personnel
New View
• Error is a symptom of
deeper trouble
• To explain failure, look
for the system failure
• Explore how actions and
assessments made
sense at time
• Replacing people leaves
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 off! 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
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Human errors occur because of:
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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
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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
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Incident report
Health records
Policies
Equipment&
maintenance records
Audit data
• Photographs
• Staff rotas
• Risk assessments
• Training records
• Witness accounts
• Interviews
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
has broken his crown and patient 2 has had a bad
fall
Paramedic crew arrive at the area but
cannot locate patients. Patients finally
located and taken to local A and E dept
which is closed.
Supplementary
Information
Very distressed patients, one with severe head
trauma and patient 2 (partner) has cuts and
bruises to legs, chest and a suspected twisted
ankle.
Local A+E closed due to a broken water
main. Asked if patients wanted to go to
nearest alternate A+E but patients
disappear. Later patient 1 Male found
dead in bed aspirated on vomit.
Good Practice
None
None
Care/Service Delivery
Problem
Failure to fully assess and document health of
patient
Ambulance slow, Local A+E shouldn’t
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
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Nurses coffee room
Social Worker
With patient 1
With patient 1
With patient 2
Dr 1
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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
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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 ?
Why ?
I have just been given a
parking ticket
Parked in a 10 minute max
parking zone and time
expired
Why ?
Held up in a queue at the local
bakery
Why ?
Why ?
The till was inoperative
Why ?
Bakery had forgotten to
extend maintenance contract
Till had not been serviced by
manufacturers
Root
Cause
Patient
Factors
Equipment and
resource
factors
Individual
Factors
Task
Factors
Working
condition
factors
Team
Factors
Organizational
and strategic
factors
Communication
factors
Education and
Training
factors
NPSA Contributory Factor
Framework
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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
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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
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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!