Root Cause Analysis

1. GP Risk Management Tutorials Root Cause Analysis Learning and Sharing Good Practice GERAINT LEWIS-PRIMARY CARE RISK ADVISER

2. 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

3. 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)

4. 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

5. 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

6. 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.

7. Root Cause Analysis To be thorough RCAmust 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

8. 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?

9. 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

10. 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

11. 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 Two Views On Human Error • 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

12. 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’

13. Group Work 1 Can you think of one instance where you have made: • A Violation • A Mistake • A lapse • A slip

14. 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

15. Systems approach • “The systems approach is not about changing the human condition but rather the conditions under which humans work”. J. T Reason, 2001

16. Process for RCAs • STEP 1: Agree facts of event • STEP 2: Establish causality • STEP 3: Produce Action Plans

17. CASE EXAMPLE: The Jack and Jill story

18. 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?

19. RCA - Gathering the information • Incident report • Health records • Policies • Equipment& maintenance records • Audit data • Photographs • Staff rotas • Risk assessments • Training records • Witness accounts • Interviews

20. 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.

21. Timeline

22. Tabular timeline

23. Time-person gridIf Jack had made it to A+E!! What were they doing over a 20 minute period in the busy A+E Department

24. 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

25. Step 2: Causality • Determine pertinent areas • Focus on pertinent areas • Formulate causal statements

26. 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?

27. QUALITATIVE RISK ASSESSMENT MATRIX – LEVEL OF RISK (Based on the AS/NZS 4360:1999 Risk Management Standard)

28. 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

29. 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 expired Why ? 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

30. Individual Factors Patient Factors Task Factors Team Factors Education and Training factors Equipment and resource factors Working condition factors Organizational and strategic factors Communication factors

31. 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

32. Step 3 The Action Plan

33. 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!

34. 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

35. 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)

36. 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

37. RCA Summary • Gather the facts. • Determine sequence of events. • Identify contributing factors. • Select root causes. • Develop corrective actions & follow-up plan.

38. 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

39. FEEDBACK AND QUESTIONS! Thank you for listening!