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 ?

Todays 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
organisations 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
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
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
Old View New View
Human error is a Error is a symptom
cause of accidents
of deeper trouble
To explain failure, you
To explain failure,
must seek human
failure look for the system
Find peoples
failure
incorrect Explore how
assessments, wrong actions and
decisions, bad assessments made
judgments sense at time
Get rid of bad Replacing people
apples replace with
leaves problems in
new personnel
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
 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
 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

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
Incident report Photographs
Health records Staff rotas
Policies Risk
assessments
Equipment&
Training
maintenance
records
records
Witness
Audit data 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 wont 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 Very distressed patients, one with
Information 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 Failure to fully assess and document Ambulance slow, Local A+E
Delivery Problem health of patient shouldnt 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 With patient 1 ? Nurses coffee room

Assistant

Social Worker With patient 1 With patient 1 With patient 2

Dr 1 ? ? 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
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-Ive 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
Why?
expired 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
 Task Individu Team Communicati
Patient
Factor al Factor on factors
Factors
s Factors s

Equipment Organization Education

Working
and al and and
condition
resource strategic Training
factors factors
factors factors
 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
 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

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
Dont 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

Gather the facts.

Determine sequence of events.
Identify contributing factors.
Select root causes.
Develop corrective actions & follow-
up plan.
And finallya 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!