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 OrganisationWorld 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-toface
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
Human error is a
cause of accidents
To explain failure, you
must seek human
failure
Find peoples
incorrect
assessments, wrong
decisions, bad
judgments
Get rid of bad
apples replace with
new personnel

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

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
2.A
3.A
4.A

Violation
Mistake
lapse
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:
event

Agree facts of

STEP 2:

Establish causality

STEP 3:
Plans

Produce Action

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
Health records
Policies
Equipment&
maintenance
records
Audit data

Photographs
Staff rotas
Risk
assessments
Training
records
Witness
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 Lanepatient 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
Information

Very distressed patients, one with

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
Delivery Problem

Failure to fully assess and document

health of patient

Ambulance slow, Local A+E

shouldnt have been closedDisaster 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
Assistant

With patient 1

Nurses coffee room

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 ?

Why?

I have just been given a

parking ticket

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?
Why?

Bakery had forgotten to

extend maintenance contract

Till had not been serviced by

manufacturers

Root
Cause

Patient
Factors

Equipment
and
resource
factors

Task
Factor
s

Individu
al
Factors

Working
condition
factors

Team
Factor
s

Organization
al and
strategic
factors

Communicati
on factors

Education
and
Training
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 & followup 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!