Root Cause Analysis

1
Root Cause Analysis
1 Day Foundation Programme
2
(No Transcript)
3
Objectives for the day

• To increase understanding of the theory
  underpinning RCA
• To provide you with an overview of the RCA
  Process
• To provide skills in some of the RCA tools
• To demonstrate the advantages of using a
  systems based approach to PSIs

4
Patient Safety A global issue
5
Money and the media
6
Other Costs

• Costs to the NHS healthcare system
• adverse events cost around 1 billion/year in
  hospital stay alone - average 8.5 extra bed days
  attributable to incidents
• gt400 million clinical negligence settlements/year

• Costs to our staff
• staff feeling persecuted and quitting the service
• life long affect on the quality of life

7
Background

• An organisation with a memory
• Building a safer NHS for patients

8
NPSA Guidance

• Seven Steps
• For all care settings
• Focused for primary care
• Checklist for chief executives
• Training for clinical leaders

9
Seven Steps to Patient Safety
NPSA summary guide to good practice

• Build a safety culture - Incident Dec Tree, Safe
  Cult Surv
• 2. Lead and support staff - PS e-learning
  programme, CEO Checklist,
• 3. Integrate risk management activity
• 4. Promote Reporting - National Reporting
  Learning System
• 5. Involve patients and public Being open
• 6. Learn and share good practice Root Cause
  Analysis
• 7. Implement solutions to prevent harm

10
How are PSIs reported?
11
There is a need to learn from patient safety
incidents a systems view is needed

• Human errors are induced by system failures.
• Evidence from other high reliability industries
  suggests that systematic investigation of adverse
  incidents is effective.
• Root Cause Analysis (RCA) is one approach

12
Root Cause Analysis

• What is RCA
• The Theory Underpinning the Process

13
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 (2001)
described the necessary steps to set up the new
national system. These included building
expertise within the NHS in root cause analysis
7 Steps to Patient Safety (2004) help local
organisations ensure that the investigation team
they create is proficient in RCA by providing
both online and face-to-face training.
14
Why RCA?

• In depth analysis of a small number of incidents
  will bring greater dividends than a cursory
  examination of a large number
• (Vincent and Adams 1999)

• RCA is a structured investigation that aims to
  identify the true cause(s) of a problem, and the
  actions necessary to eliminate it (Anderson and
  Fagerhaug 2000)

15
What is RCA?

• Root cause analysis is a systematic
  investigation technique that looks beyond the
  individuals concerned and seeks to understand the
  underlying causes and environmental context in
  which the incident happened
• Seven Steps to Patient Safety 2004

16
(No Transcript)
17
Why do people get things wrong?
Sorry boss I was doing my best
18
Understanding adverse incident causes
Person centred approach
Systems approach
19
What is Human Error ?

• We all make errors irrespective of how much
• training and experience we possess or how
  
• motivated we are to do it right.
• Failures are more serious for jobs where the
• consequences of errors are not protected
• Reducing error and influencing behaviour -
  HSG48

20
Human Behaviour
There are good reasons why we behave as we do
If we understand those reasons we can understand
why errors have occurred in the system
We can be more effective in producing systems
that minimise error likelihood or consequences
21
Human Behaviour is Predictable !
22
It wont do any harm, not this once, I wont get
caught
23
Rasmussens Skill, Rule and Knowledge (SRK) Model
Automatic, familiar well practiced routines
Conscious Thought
Skill
Learning rules and rehearsing routines
Rule
Novel task
Knowledge
24
How do accidents happen?
Organisation and processes - Deficiencies
Prior conditions - basic causes (contributory
factors)
Unsafe acts (CDP/SDP) - active failures (SRK
errors)
Multiple Defences
Patient Safety Incident
25
How do accidents happen?
Prior conditions - basic causes (contributory
factors)
Accident
26
Contributory Factors

• Patient factors
• Individual factors
• Task factors
• Communication factors
• Team Social factors
• Education Training factors
• Equipment and Resource factors
• Working Condition factors
• Organisational management factors

27
How do accidents happen?
Prior conditions - basic causes (contributory
factors)
Unsafe acts (CDP/SDP) - active failures
Accident
28
(No Transcript)
29
Myths

• the perfection myth
• if we try hard enough we will not make any errors
• the punishment myth
• if we punish people when they make errors they
  will make fewer of them

30
Incident Decision Tree
31
ERROR TYPES based on the work of Reason,
adapted by NPSA
Unsafe acts
Skill based errors Memory failures
Skill based errors Attentional failures
32
Aoccdrnig to a rscheearch at Cmabrigde
Uinervtisy, it deosn't mttaer in waht oredr the
ltteers in a wrod are, the olny iprmoetnt tihng
is taht the frist and lsat ltteer be at the rghit
pclae. The rset can be a total mses and you can
sitll raed it wouthit porbelm. Tihs is bcuseae
the huamn mnid deos not raed ervey lteter by
istlef, but the wrod as a wlohe.
33
How do accidents happen?
Organisation and processes - Deficiencies
Prior conditions - basic causes (contributory
factors)
Unsafe acts (CDP/SDP) - active failures (SRK
errors)
Multiple Defences
Patient Safety Incident
34
Barriers, Controls and Defences

• Human Action Barriers
• Administrative Barriers
• Physical Barriers
• Natural Barriers time, distance, placement

35
Which dial turns on the burner?
Stove A
Stove B
36
(No Transcript)
37
Getting Started

• A Patient Safety Incident (PSI) is
• Any unintended or unexpected incident(s) that
  could have or did lead to harm for one or more
  persons receiving NHS funded healthcare
• Which PSI requires an RCA?
• PSI causing death or severe harm
• Frequently occurring PSI / Prevented PSI

38
Classifying Incidents

• Use organisational procedure for PSI
  classification
• Classify according to

• the degree of harm or damage caused at the time
• its realistic future potential for harm if it
  occurred again

39
NPSA Definitions
PATIENT SAFETY INCIDENT Any unintended
or unexpected incident(s) which could have or did
lead to harm for one or more persons receiving
NHS funded care
40
Select People for the RCA Investigation Team
Incidents causing death or severe harm

• Multidisciplinary group of 3-4 persons
• One of which should be fully trained in incident
  investigation and analysis
• Objective attitude
• Good organisational skills
• Use of experts

41
Select People for the RCA Investigation Team
Contd
Near Miss or Less Serious Event Investigations
(high frequency)

• Can be undertaken by one person e.g. ward manager

For all incidents investigators need to be able
to demonstrate competence, credibility,
objectivity and a degree of independence
42
Initial Scoping of the PSI RCA Investigation

• Consider
• How far back in the episode of care you need to
  go.
• Do other organisations need to be involved?
• What information you need?
• Whether the investigation requires project
  management e.g. project plan