Beyond Root Cause Analysis: Exploring the Causes of Bad Outcomes

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Beyond Root Cause AnalysisExploring the Causes
of Bad Outcomes

• Robert L. Helmreich, PhD, FRAeS
• University of Texas Human Factors Research
  Project
• The University of Texas at Austin
• Royal Australasian College of Surgeons
• Perth, WA
• May 9, 2005

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Why Root Cause Analysis?

• Root Cause Analysis (RCA) has the commendable
  goal of improving safety by determining the
  causes of adverse or sentinel events

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The downsides of RCA

• RCA normally takes place after an adverse or
  sentinel event
• Individuals at the sharp end are often distraught
  and guilt-laden over the event
• Findings may be used to punish individuals
  involved
• Fear may motivate failure to disclose

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The biggest limitation

• RCA is reactive not proactive
• In aviation, organizational interventions
  following an accident or incident are referred to
  as tombstone regulation

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The fallacy of a root cause

• In a complex environment such as the operating
  theatre or the aviation system, bad outcomes are
  seldom the result of a single failure or root
  cause

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The reality of causality

• Adverse and sentinel events most often reflect a
  confluence of threats to safety with or without
  human error by those at the sharp end of the
  system

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Medical evacuation accidentsA case study

• Helicopter medical evacuation is, in the US, one
  of the most risky aspects of the aviation system

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The medevac experience

• Between 2000 and 2004, the US National
  Transportation Safety Board investigated 11
  accidents involving medevac helicopters
• 10 of the 11 were ruled to be the result of
  pilot error the root cause
• In the 11th, the tail rotor fell off

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Beyond pilot error

• Burrowing into the context of each of the pilot
  error accidents, we find a litany of contextual
  factors that were critical to the event

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Contextual factors in medevac accidents

• Darkness
• Fog and rain
• Terrain
• Power wires
• Criticality of patient condition

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Broadening the Perspective
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A framework for investigation of close calls,
adverse and sentinel events

• Model includes both technical and interpersonal
  components of performance

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Team Performance Model
Outcomes
Processes
Inputs
Team and Task Performance Outcomes
Team Functions
Team Input Factors
Task Completion Task Quality
Individual and Organizational Outcomes
Technical Task Enactment CRM/Threat and Error
Management Behaviors Team
Formation/Coordination Communications
Decision Making Situation Awareness
Procedural Compliance
Individual Aptitudes Physical Condition Organizati
onal Rules Physical Environment Professional
Culture Organizational Culture National Culture
Operational Efficiency Attitudes Morale
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Input and Process Factors
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Medical Team Outcomes
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Digging DeeperThe Threat and Error Management
Model (TEMM)
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What is a threat?

• A threat to safety is a condition that originates
  outside an individuals or teams influence that
  must be actively managed to avoid becoming
  consequential to safety

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Threats to safety in medicine(USA)
Organizational Organizational Culture Scheduling
Staffing Experience levels Work Load Error
policy Equipment issues
System - level National culture Health-care
policy and regulation Payment modalities Medical
coverage
Professional Proficiency Fatigue Motivation Cultur
e (Invulnerability)
Patient Primary illness Secondary illness Risk
Factors Atypical response to treatment Ongoing
management
Expected Events and Risks Unexpected Events and
Risks
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Threat and Error Management Model
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Latent Threats

• Aspects of the system that predispose the
  commission of errors or can lead to undesired
  aircraft states

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Latent Threat Examples

• Inadequate management oversight
• Inadequate regulatory oversight
• Flawed procedures
• Organizational culture and climate
• Scheduling and rostering practices
• Performance assessment practices
• Inadequate accident and incident investigation

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Error
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Typology of Observable Team Error

• 1. Task Execution Unintentional physical act
  that deviates from intended course of action
• 2. Procedural Unintentional failure to follow
  mandated procedures
• 3. Communication Failure to transmit
  information, failure to understand information,
  failure to share mental model
• 4. Decision Choice of action unbounded by
  procedures that unnecessarily increase risk
• 5. Intentional Noncompliance Violations of
  formal procedures or regulations

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When things go wrong
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Investigating adverse events

• Use the team process and threat and error
  management models to classify the threats to
  safety in the organization
• Specify individual and group error
• Focus on the management (or mismanagement) of the
  threats and errors in the operational environment

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Using data

• Develop a safety change process to act on safety
  data and prevent recurrence of the event or
  threat
• Policy
• Procedures
• Training and qualification

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Be proactive
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Encourage reporting

• Institute local reporting system that encourages
  and rewards individuals for reporting close
  calls, threats to safety and errors
• Non jeopardy
• Act on information
• Feedback corrective action to those who report

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Comments and Questions
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• The University of Texas
• Human Factors Research Project
• www.psy.utexas.edu/HumanFactors