Effective Event Analysis

Using Root Cause Analysis

 Basic Principles
• “The best people can sometimes make the worst mistakes”
James Reason 2003
• “Errors reflect internal or external influences on performance
because the operator wants to perform well but did not
because of systems characteristics”
Strauch 2002
• “ Too often lessons are identified but true ‘active’ learning does
not take place because the necessary changes are not
embedded in practice”
» Organisation with a memory 2002
 Understanding adverse incident causes –
which approach will make it safer?
Person-centred approach Systems approach
Individuals who make Poor organisational design
errors sets people up to fail
are ‘careless, at fault,
reckless’
Blame and punish Focus on the system rather
than the individual
Remove individual Change the system
= improve safety = improve safety
 A safety culture is….
A culture where staff have a constant and
active awareness of the potential for things
to go wrong

•A culture that is open and fair, and one that

encourages people to speak up about
mistakes
 Rasmussen’s Levels of
Performance
• Skill Based Performance
• Automatic control of routine tasks

• Rule Based
• Matching prepared rules to trained for problems

• Knowledge based
• Conscious, slow, effortful attempts to solve new problems
 Control Methods

Situations
Conscious Mixed Automatic

Routine
Skill Based

Trained for Problem

Rule based

Novel Problem Knowledge

based
 Errors

• “An error is the failure of planned actions to

achieve their desired goal, where this occurs
without some unforeseeable or chance
intervention” Reason 1990
 Types of Error
Slip, trip, lapse, fumble
– The plan is correct but the action fails ( failure of
action or memory)
– Recognition Failures

– Problem detection Failure

– Memory Failure
 Mistakes
• Rule Based Mistake
– Misapplying a good rule
» Making assumptions

– Applying Bad Rules

» Bad habit formation

• Knowledge Based Mistakes

– Wrong action is chosen due to lack or inappropriate knowledge base.
 Violations
• Routine Violations
• Deliberate deviations from accepted codes of practice. Used to
avoid unnecessary effort or work quicker

• Situational (Reasoned) Violations

• When the procedure is impractical due to time constraints,
unusual situations or thought to be in the best interest of a third
party
 Violations
• Reckless
• Deviation from the protocol where damage can be easily
foreseen and ignored although no harm is intended.

• Malicious
• Where there is an intention to cause harm - Shipman, Alitt
 Systems
“ Individuals by the very nature of being human are
vulnerable to error. Although individuals are the
focus of the error, errors also happen because of
the systems in which people work. More often than
not, a single error has multiple sources. Reducing
errors also will require us to design and implement
more error-resistant systems.”
Gordon Spencer
President & CEO American Hospital Association
Quoted in ‘Building a Safer NHS for Patients’
2001
 Root Cause

• The most basic reason for a problem,

which, if corrected, will prevent
recurrence of that problem
» Ammerman 1998
 Process of Effective Incident
Investigation
• Identify the Incident to be investigated
• Chart the event with current knowledge
• Gather documentary and other evidence
• Revise chart
• Arrange and carry out interviews
• Revise chart
• Identify Causal Factors
 Process
• Analysis Causal Factors
• Decide on Options for Improvement
• Provide report
• Ensure implementation of Improvement
Plans
 What to Investigate?
• Investigations take time
• Investigations cost money
• Investigations can upset staff
• Type of incident to be investigated should be
clearly identified in the Incident Procedure
Why don’t people report incidents
• Potential Recrimination
• Fear of Disciplinary Action
• Fear of Peer Teasing
• Fear of involvement in the investigation
• Lack of motivation to report
• Lack of Management commitment
• Sporadic Interest
• Fear of Liability
• Confusion about what to report
Disciplinary Action

Trust Policies
• Operational Policy and Procedure for
reporting and management of accidents
and incidents.
• Incidents, accidents and the Trust
disciplinary process- Guidelines for
managers, Clinical Directors and
employees
THE INCIDENT DECISION TREE NHS Confederation / National Patients Safety Agency

Start Here for each

individual involved

Deliberate Harm Test Incapacity Test Foresight Test Substitution Test

Were the actions as intended? Does there appear to be
evidence of ill health or
substance abuse?
No
Yes Yes
Were the adverse Does the individual have a
consequences intended? known medical condition?
YES No
Did the individual depart Would another individual Yes
from agreed protocols or coming from the same
safe procedures? professional group,
No No possessing comparable
qualifications and
experience behave in the
same way in similar
circumstances?
Yes
No
Yes Yes
Were protocols and safe Were there any deficiencies in
procedures available, workable, training experience or supervision?
intelligible, correct and in
routine use?
No
Yes
Yes
Is there evidence that the Were there significant mitigating
individual took an unacceptable circumstances?
risk? Yes
No
No

Consult NCAA or relevant
regulatory body.
Advise Individual to consult
Trade Union Representative
Consider
 Suspension
 Referral to Police and
disciplinary/regulatory body
 Occupational Health referral
Consult NCAA or relevant Advise Individual to Consult NCAA or relevant Systems
regulatory body. consult Trade Union regulatory body. Failure
Advise Individual to consult Representative Advise Individual to consult
Trade Union Representative Consider Trade Union Representative
Consider  Corrective training Consider Review
 Occupational Health referral  Occupational Health  Referral to System
 Reasonable adjustment to referral Disciplinary/regulatory body
duties  Reasonable adjustment  Occupational Health referral
 Sick leave to duties  Reasonable adjustment to
 Improved supervision duties
 Suspension
Based on James Reason’s Culpability Model
HIGHLIGHT ANY SYSTEM FAILURES IDENTIFIED
 Near Misses
• “ An opportunity to improve environmental, health
and safety practice based on a condition, or an
incident with potential for more serious
consequence.”.
– Unsafe conditions
– Unsafe behaviour
– Events where injury could have occurred but did not
– Events where property damage could result
– Events where a safety barrier is challenged
– Events where environmental damage could occur

• “ Any mistake or failure that could have caused an

incident, accident or other serious performance problem
but did not because of one or more safeguards or other
factors (such as luck)”.
REPORTED NEAR MISSES
Space Shuttle Challenger – 1986.

 7 Killed.
 Engineers had reported degradation in ‘O’ ring sealers
dating back to 1982
 The night before management had been warned that if
ambient temperature was below 36 degrees disaster would
follow.

The Hindustan Refinery – 1997

 60 People Died10,000 metric tons of petroleum based
products released into air
 Written complaints of corroded and weakened transfer
lines ignored

The Morton Reactor Explosion – 1998

 9 Serious Injuries
 Management failed to identify warnings of excessive
temperature reports

The Paddington Disaster – 1999

 31 People Died
 From 1993 –1999 –eight near misses or ‘signals passed at
danger’ (SPADS) had occurred at that location (Signal
109) one of 22 with the greatest number of failures.
Support Staff and Patients
• Being Open Policy
• Supporting staff when things go wrong
 Collecting Information
• Preservation system for evidence
• Secure location
• Diagrams & Sketches
• Photographs – with log of each photo
• Video
• Preservation system for evidence
• Electronic Data
• Medical Records
• Copies and means of up-dating if further treatment carried
out
• Medical Reports
• Interview records
• Statements
 Collecting Information
• Physical Evidence
Collecting Information
Collecting Information
 Cause and Event Charting
• Event and Causal factor charting is an analysis
tool whereby you chart the relationship of
events, conditions, changes, barriers and
causal factors on a timeline
• Used when
– Equipment fails
– Human actions cause problems
– Barriers fail
– Many factors are evident
 Constructing a Cause and Effect Chart
• Define scope of chart
– Terminal Event
– Initiating Event

• Obtain initial information and documentation

• Begin constructing preliminary time line of
events with relevant conditions
• Carry out interviews, RCA tools
• Review Chart, events and conditions
• Identify and add causal factors and failed
barriers
Cause & Effect Charting
EVENT CHART

The most serious event took place

The reason for the investigation
Incident
Enclosed in a circle and connected by an arrow

Each Box is a step in the sequence – one action

Event per box
What did what or who did what
Use job titles not names

Event Events in dashed boxes are yet to be proven

Explain the actions that took place in an

Conditions attached box
Factual and Non Judgemental

Conditions Conditions yet to be confirmed – room for

further questions

Causal Factor – to be attached to

condition
 Example - Cause and Effect
Chart Taken to Accident and
Emergency for
1/2/3/ 13.50 1/2/3 14.00hrs Pt. walks Patient slips treatment
Domestic Assistant Patient leaves Ward onto wet and injures
start washing main 18 main entrance corridor back
Corridor Floor

Domestic not No ‘wet floor’

reminded to put out signs in place
wet floor signs

Washes whole width of

Domestic not trained to corridor no dry space
wash corridors in strips for walking
Chart the Event - Mr Charlton
Mr Charlton - Aged 41yrs
19/3/00 22/3/00 24/3/00 26/3/00 Patient 27/3/00 Pt. Decides to go to
Patient undergoes surgery - Pt complains of chest Pt complains of discharged from City Pt visits GP County Hospital –
for repair of hiatus hernia pain pain to nurse Hospital A/E Dept

Nurse newly qualified Patient referred

Pain attributed to not trained in spotting back to City
post op soreness postoperative Hospital
problems Pt dissatisfied
with City
Hospital

On the job
No policy for post No further tests training
op testing for carried out provided ‘as
chest pain and when’

SHO Been on Nurse doesn’t

call for 3 days inform anyone
senior of chest
pain

Investigations Leaking suture line 29/3/00 21/3/01

carried out at found to have Remedial surgery carried Patient files
A County Hospital caused out at County Hospital claim for
inflammation and malpractice
damage to left lung
 INTERV IEW
Post event information, delay, instructions for
response and questioning methods

 Interviewing
Guidelines
 Inferences  Predetermined
 Stereotypes Reported Perceived Hypotheses
Interviewee Interviewer
 Partisanship Event Report  Questioning
 Scripts strategy
 Schema
 Frame of Reference
Recalled Event
Stored Report

Stored memory

Event factors W itness factors Recalled

 Distance  Stress Report
 Lighting Perceived By witness  Alcohol
 Violence/ W eapon  Drugs
 Length of observation  Selective Attention
 W itness Involvement
TBR
EVENT Record of Event

M emory Theory & Interview Process (Kohnken 1995)

50
 Interviewing
• Information is the Lifeblood of an
Investigation
• Witness information is critical to an effective
investigation
• Memory is fragile and can be influenced
• Poor questioning technique will lead to errors
 Interviewing - Preparation
• Decide whom to invite as second party
• Consider the environment
• Have white board or flip chart for charting
• Prepare the question areas you are going to
cover
• Carry out the interview around 72 hours
• Have interview checklist ready
 Interviewing - Practice
• Personalise the interview - introduce
yourself and guest and explain purpose of
the exercise
• Emphasise the fact finding nature of the
interview – no fault
• Tell interviewee how the information will
be used explain what is expected of the
interviewee
• Transfer of control
 Interview - Practice
• Start by general questions about them - get
interviewee to relax
– How long have they worked in the speciality?
– How long have they been trained etc.?
– Obtain a baseline emotional response

• Be aware of the Interviewee’s state of mind

• Open v Closed questions
• Concentrate on what was as fault, not who
was at fault
 Interviewing
• Ask what they
• Did?
• Saw?
• Heard?
• Smelled?
• Review the incident on the flip chart/white board
• Clarify each event if required
 Interviewing - Ending
• Ask if there is anything you have missed or
they would like to mention
• Thank them for their time
• Ask them to contact you if they remember
anything else relating to the incident – give
them your telephone number or card
• Record the interview
• Assist with statements if required
 Interviewing - Do Not!
• Do not interrupt!
• Ask repeated similar questions
• Use verbal loopholes
• “I know this is a difficult question but…..?”

• Give excuses for questions – just ask them!

• Allow staff to collude and ‘cover’ each other
• Tell staff not to talk to one another about the incident
• Interview as soon as possible after the event (72 Hours)
 Interviewing - Do not

• Forget staff may ‘create’ information. Watch

for signs of lying or stress.
• Allow pre-conceptions to cloud judgement
• Use negative phraseology
 TASK ANALYSIS
• Breaks down tasks into steps and sub steps by identifying: -
• Actions
• Instructions
• Conditions
• Tools
• Materials
– Associated with the task
• Concentrate on task steps and how they are performed.
• Review – documents, protocols, logs, technical manuals
• Process helps compare what happened with what should
have happened
Paper Exercise Task Analysis
• Obtain preliminary information – who, what,
where, when, the task was being carried out.
• Determine scope of exercise
• Obtain available information about the task
requirements.
• Divide task into components and list each action
on task analysis sheet with who performs task.
• Discuss process with external expert
• Review information to prepare questions
Walk Through Task Analysis
• Staffs are requested
Purpose: to demonstrate
- To simulate the performed.
the task being task without
carrying it out.
• Obtain preliminary information – who, what, where,
when, the task was being carried out.
• Determine scope of exercise
• Obtain available information about the task
requirements.
• From above, produce guide outline of task to use as
base for questioning and observation
 Walk Through Task Analysis
• Check off each step, as it is done – note any
discrepancies.
• Use usual team/individual that carries out the
task
• Observe staff carrying out re-enactment of
task
• Summarise and consolidate any problem
areas
 TASK ANALYSIS

Task to be Analysed STARTING THE CAR

Step WHO Required Action Component Tools Remarks/Questions

1 Driver Ensures that weekly checks
and regular services has been
carried out
2 Driver Checks that it is safe to
approach the car and than no
traffic may pose a Hazard
3 Diver Carries out visual check of car
to ensure tyres are inflated
and that it is road worthy.
4 Driver Unlocks car
Driver Removes Key if key is used
5
Driver Opens car door by pulling
6 handle upwards
If driver does not know
car then s/he should
look for service manual
and re- check
according to
manufacturers
instruction book
Tyre pressure should
be checked weekly with
water and oil checks
Driver’s side door lock Key / Fob – press button A
– see diagram Disengages alarm – all
door unlocked
Door lock
Door handle Handle spring loaded –
will return to place
Step WHO Required Action Component Tools Remarks/Questions
7 Driver Enters cabin and sits in Driver’s seat Left leg first
driver’s seat and closes balancing on right
door leg. Steadies
him/herself with left
hand on steering
wheel to pull in right
leg
8 Driver Attains comfortable Driver’s seat.
position with both feet in
foot well
Driver Checks visibility of all Will leave car and
9 windows and mirrors clean car windows if
visibility is restricted
10 Driver Checks that all lights are Lights – front full, Light switch May need assistance
working dipped and drake to check rear brake
lights
11 Driver Checks that the car is in Gear lever Wiggles it to ensure
neutral it is not engaged
12 Driver Checks that hand brake is Hand brake lever Pulls upwards until
engaged it can move no
further and is locked
in position
13 Driver Releases seat belt Seat belt Reaches with left
hand over right
shoulder to pull
seatbelt downwards
and to the left
 WHY ANALYSIS

Follow path of questions asking the rhetorical question “Why” – Descend five levels or until the Root Cause is Found
NO
MANAGEMENT
MEAL TROLLEYS NO PLANNING FOR
MEALS GIVEN SYSTEM FOR
INADEQUATE FOR REPLACEMENT WHEN
OUT COLD CONTROL OF
DEMAND OBSOLETE EQUIPMENT

NO-ONE DEDICATED UNDER STAFFING NO RE-PROFILING

TO GIVING OUT MEALS EXERCISE CARRIED
OUT

INCRESING POORLY WRITTEN NO POLICY TO

LEVELS OF PRESCRIPTIONS MEASURE AGAINST
COMPLAINTS MEDICATION
FROM ERRORS
PATIENTS
ABOUT NO AUDIT OF QUALITY
OF PRESCRIPTIONS NOT THOUGHT
WARD 2
NEEDED
NO MANAGEMENT
SYSTEM FOR
QUALITY
UNDER STAFFING NO RE-PROFILING
EXERCISE

STAFF BRUSQUE
AND UNHELPFUL
NO TRAINING IN QUALITY NOT THOUGHT
SERVICES NEEDED
 Barrier Analysis
• Barrier Analysis can be used in at least two
ways in an investigation: -
• To help identify causal factors
• To help identify and evaluate the proposed corrective action
 Types of Barrier
• Physical Barriers
• Insulation on hot pipes,Guard rails on stairs, Fences around
property

• Natural Barriers
• Distance,Time, Placement

• Human Action Barriers

• Evacuating a building when the alarm sounds,Checking the
temperature of water in a bath

• Administrative Control Barriers

• Keep Out signs, Relevant policies,Training Supervision
 Performing a Barrier Analysis
• Identify issue to be analysed from Cause and
Effect chart
• Brainstorm hazards, barriers and targets for the
issue. Use appropriate experts if required.
• Consider the Hazards to Targets under the
following headings: -
 People (Safety hazards)
 Property
 A productivity and profit
 Environment
 Quality
 Performing Barrier Analysis II
• Organisers and the list into hazards, or barriers,
and targets
• Evaluated the list
• Evaluate the strength of each barrier by rating them on either strong,
average, or weak.
• For a barrier that involves a human action lower the strength by at least
one level

• Record findings
 Change Analysis
• Principle:_

• When a task, process or machine has

worked effectively and then fails –
something must have changed to cause
the problem
 Change Analysis - used when
• Equipment that has operated well in the past starts
to have problems
• Two pieces of identical equipment have different
reliability
• A change is suspected to have contributed to the
incident
• Two jobs are similar, but the problem rate differs .
• A formal enquiry has been requested
• Other Root Cause Analysis tools may not have
identified the cause
 Change Analysis - Process
• Identify the factors that Influence
Performance
– Ask an expert and involve staff
– Review literature
– Involve manufacturer
• Consider the style of document to record findings.
– List factors
– List correct practice
• Consider the questions you need to ask
– List what happened during event
– Note the difference
• List positive and negative findings; ask whether the
difference caused the problem.
• Add this information to the Cause and Effect Chart
 Change Analysis - worked
example
• Mr Smith, 64yrs. – steel worker, was
scheduled for amputation of right leg due
to circulatory problems caused by
diabetes. There were problems with the
left leg that would probably result in
amputation at a later date. After surgery it
was discovered that the wrong leg had
been amputated.
 Change Analysis - Factors for
selection
• Factors that would influence the selection of the
correct limb:-
– The surgeon’s knowledge of the patient’s condition
– Expectation that the operation site would be damaged
– The medical record and consent form should identify the area
of surgery fully and clearly
– The theatre list should be typed and written clearly
– Marking the site as per procedure
– The preparation of the site in theatre follows procedure
– The alertness/fatigue of theatre team
– The trust that the surgeon had in his team expecting that they
work correctly and have the correct leg draped
 C hang
Factors that Interview When Correct When wrong Did
Influence Leg Questions leg is selected leg is selected change
selection influence
selection
Knowledge of Tell us about Knowledgeable Same No
Patient knowledge of this
patient compared
with other
patients you have
operated on?
Theatre List Was the leg Correct List changed at Yes Yes
identified on the information last minute. New
theatre list? hand written list
Did you List reviewed by provided which
personally review authorising was not checked
the list prior to surgeon by surgeon
commencement
of list?
Marking of site Were marking Skin pencil used Biro used to Yes Yes
used to denote to apply X to leg make X as
correct site and after checking patient crossed
checked against with medical his leg the mark
medical records? records rubbed on to the
other leg
Knowledge of Did members of Correct leg Incorrect leg Yes Yes
other team the team indicate draped draped
members which leg was to
be amputated?
Surgical site Who prepared the Standard pre by Surgical Yes Yes
preparation leg. Were drapes surgical assistant got
used|? Anything assistant information
abnormal? from revised list
Carried out pre
correctly
Fatigue Ask about hours Normal Normal No
on duty and
alertness prior to
procedure?
Expectations Did you have any Expect to Draped limb was No
expectations that amputate a diseased
may have diseased limb
influenced your
selection of the
limb to amputate?
 Changes that Contributed to the
Problem
• Registrar marked the site using Biro rather than an
indelible marking pen.
• SHO provided hand written theatre list, failed to write
“Left” fully
• Limb draped after reading theatre list and noting site
– omitted to check medical records and consent
form
• Draping not carried out by surgeon who knew the
patient
 DEVELOPING CORRECTIVE
ACTIONS
• Purpose
– To formally identify and evaluating alternative corrective actions for
each Root cause and selecting the Corrective Actions to be
recommended.

• Definition
– A Corrective Action is the Countermeasure to be taken against the
Root Cause to alleviate or reduce the probability that the problem
will recur.
 Evaluation Of Alternatives
• Consider
• Will the corrective action(s) prevent reoccurrence of the
problem?
• Is the corrective action within the capability of the Organisation
to implement?
• Does the corrective action meet the Trust’s Mission Statement?
• Have assumed risks been clearly stated?
• Is the corrective action compatible with other Trust commitments
• Can the corrective action endanger patients, staff, or visitors
 Impact of Corrective Actions
• Is there an Impact on Other parts of the Organisation?
• Audit/Quality
• Health and Safety/ Occupational Health
• Estates and maintenance
• Training Department
• Security
• Is there an Impact on Resources?
• Capital and Revenue Costs
• Developmental Costs
• Cost of quality maintenance and audit
• Impact of Implementation
• What is a reasonable timeframe for implementations
• Will training effect present workforce availability
• With their be an Impact on Regulatory Bodies e.g. HSE, MDA
 Countermeasure Matrix
Score the Effectiveness and feasibility in rate from 1 – 5;
1 being low and five – high. Multiply the two scores to
give overall rating
PROBLEM ROOT Countermeasure Feasibility Effectiveness Overall Action
CAUSE
1)

2)

3)

4)

5)
 Consider ways of monitoring the
Effectiveness of the Corrective
Action(s)
• Audit – immediate action
• Comparative before /after data
• Ensure resolution is due to corrective action
• Standardise work processes throughout the Trust
• Ensure training in new process
• Ensure long term Quality Assessment
 Report Content
• Terms of reference
• Demographic details of patient and synopsis of
incident
• History of event with dates and times
– Done as written record or Cause and Event Chart as Appendix
• Immediate Corrective Actions
• Causative factors with root causes
• Remedial Action Required
 Report Content II
• References and Attachments
• Investigating team or persons
• Circulation List
Where to now!