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Root cause analysis

Root cause analysis. Slides adapted from: the proceedings of the first workshop of Leadership mentorship for Maternal, Newborn and Child health: a programme for DCSTs in KwaZulu-Natal , 13 to 17 August 2012.KZN DOH/UNICEF/UKZN.

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Root cause analysis

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  1. Root cause analysis Slides adapted from: the proceedings of the first workshop of Leadership mentorship for Maternal, Newborn and Child health: a programme for DCSTs in KwaZulu-Natal , 13 to 17 August 2012.KZN DOH/UNICEF/UKZN. A presentation given by Dr MG Schoon, Department of Health, Free State Provence

  2. Definition Purpose • Identify causative factors and develop corrective strategies • Any event in the chain of causes that, when acted upon by a solution, prevents the problem from recurring. • To prevent adverse events/outcomes • Prevent harm • Improve quality care and patient safety

  3. Age distribution per age and sex North Cape Namakwa

  4. Access to piped water

  5. N Cape maternal, infant and mortality rates

  6. Top causes of maternal death in Gauteng NCCEMD 2012 • Non Pregnancy Related Infections 53.4% • Hypertension 22.7% • Haemorrhage 22.4% • Pre-existing medical conditions 12.7% • Pregnancy related sepsis 10.6% • Acute collapse 6.3% • Anaesthetic related 2.4% • Abortion 4.9%

  7. Causes of under-5 mortality in SA • Diarrhoeal Disease 22% • Neonatal causes 15% • Acute respiratory infection 14% • HIV contributes to at least half of child deaths in SA • 60% of deaths in the Child PIP are associated with malnutrition • 10% of children 1-9 yrs underweight* • 20% of children aged 1-9yrs stunted* CoMMiC Report 2011 *National Food consumption survey in CoMMiC Report 2011

  8. Root course analysis An effective tool for systematically identifying problems and analysing critical incidents to generate systems improvements

  9. WHY! WHY? Why……………

  10. Knowing what adverse events occur is only the first step. Most adverse events result from a complex series of behaviours and failures in systems of care. Investigation of the patterns of adverse events requires unearthing the latent conditions and systemic flaws as well as the specific actions that contributed to these outcomes. • Dr. G. Ross Baker & Dr. Peter Norton

  11. RCA 1.It is inter-disciplinary, involving experts from the frontline services; 2. Involves those who are the most familiar with the situation; 3. Continually digs deeper by asking why, why, why at each level of cause and effect; 4. Identifies changes that need to be made to systems; and 5. Is as impartial as possible in order to make clear the need to be aware of and sensitive to potential conflicts of interest

  12. Check for eligibility for RCA • Deliberate harm test • whether the actionswere as intended, not whether the outcomewas as intended • Incapacity test • Was a staff member ill or intoxicated • Foresight test • Did the individual depart from agreed protocols or safe procedures? • Substitution test • Would another individual coming from the same professional group, possessing comparable qualifications and experience, behave in the same way in similar circumstances?

  13. Cases that should not be subjected to RCA • Events thought to be the result of a criminal act • Purposefully unsafe acts (intended to cause harm) • Acts related to substance abuse • Events involving suspected patient abuse of any kind

  14. RCA (+as part of clinical audits): Success depends on involvement of the attending physician, consulting specialist and other providers

  15. RCA steps • Collect information • Causal factor charting • Root cause identification • Recommendations

  16. Process • Gather information already documented • Review health records • Flow chart/ timeline • Get additional information • Site visit • Interviews

  17. Swiss cheese model most accidents can be traced to one or more of four levels of failure • Organizational influences, • unsafe supervision, • preconditions for unsafe acts, and • the unsafe acts themselves.

  18. Ishikawa diagrams Personnel Measurements Materials Environment Methods Equipment

  19. Ishikawa diagrams Personnel Measurements Materials Shifts Alloys Callibration Training Lubricants Microscopes Suppliers Operators Inspections Angle Wear Humidity Callibration Speed Temperature Callibration Callibration Environment Methods Equipment

  20. But why? • Why are there so many maternal and child deaths associated with HIV? • But why? • Assign the role of ‘devil’s advocate’ to someone in your tribe … • “Devil's advocate role seeks to engage others in an argumentative discussion process. The purpose of such process is typically to test the quality of the original argument.” • The responsibility of the Devil’s Advocate is to ask the question: ‘But … So why?' http://en.wikipedia.org/wiki/Devil's_advocate

  21. Identify themes/categories that the factors you have identified can fit into • How do these themes/categories relate to each other? • Draw a large picture to show your thinking

  22. Root cause summary

  23. Root cause summary

  24. Recommendations • List the recommendations • Write a report regarding the findings • Suggest some implementation strategies

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