Root Cause Analysis Paper.

What is root cause analysis? e analysis (RCA) is a method of incident investigation. As such, it is a diagnostic tool

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rather than a safety solution in itself. RCA allows a systems approach (Chapter 26) to investigation Patient Safety Agency when developing a framework for patient safety investigation in the NHS. The NHS approach aligns well with investigation methods used in healthcare and other high-risk industries across the globe. SDP in the head of each fish (not the whole incident), then ana- lyse why that course of action seemed the right thing to do at that time • A few carefully analysed ‘fishbones’ focusing on key CDPs and SDPs will deliver more benefit than many completed quickly Training in systems thinking and human factors (including error types and biases) will aid impartiality and quality analysis The root causes are the most significant contributory factors 25 4. Generating recommendations and solutions Problems will rarely be resolved for the long term by applying discipline, training and updated procedures alone Training in improvement science will assist with more effective selection and implementation of solutions Why investigate? The primary aim of patient safety investigation is to learn from inci- dents and to determine what can be done to significantly reduce the likelihood of recurrence; the aim is not to apportion blame. If, during an investigation, concerns of capability, recklessness or maliciousness arise, the Incident Decision Tree (IDT) should be used to provide guidance on whether and to whom these issues should be referred. Investigation and planned management of these particular concerns should not form part of the patient safety investigation process. Chapter 9 Root cause analys or 5. Implementing solutions Amalgamate action plans from investigations. This encour ages trend analysis and a more cohesive, high-level approach to resolving common issues • Avoid conducting more and more investigations with similar outcomes. Time must be allocated to implementing solutions and monitoring their efficacy 6.Writing the Investigation Report • Use an RCA investigation report template to facilitate trend analysis, audit and shared learning 5 6 economy RCA process Investigations can be comprehensive or concise but must always Effective RCA investigation include the basic elements to help ensure they are thorough, cred- ible and actionable, and represent value for money The components for success in patient safety investigations are Set clear terms of reference and follow them. Secure adequate the same as those required for successful clinical investigations (Figure 9.1); time and skills, or record and report the impact of constraints 1 To avoid the extremes of delayed problem diagnosis and Avoid lots of concise investigations. They can prove false resource wastage, triggers or indications for conducting an investi- 1 Gathering and mapping the information gation must be correctly identified. You have to understand exactly what happened leading up to 2 To obtain a good-quality, accurate picture of the problem, data an incident before you can fully understand why it happened gathering must be conducted by those skilled in the process. Investigative interviewing should focus more on listening 3 The findings from the collection of data must be robustly inter- preted and credible conclusions drawn by someone with analyti . Consult the patient and family as part of the investigation; they have a unique perspective and valuable information to share SDPs) – this stage involves identifying all the points at which: care and service delivery problems (CDPs and something happened that should not have happened; or something that should have happened did not a fishbone diagram (or Ishikawa diagram or cause- for this process. as shown in Figure 9.2, place one CDP or than on asking questions 2 Identifying cal skills and an understanding of the ‘anatomy, physiology and pathology of the issue. 4 To ensure that improvement is achieved and measurable, expert selection, application and monitoring of effective treatment and remedial action are required. 5 If meaningful learning and improvement are expected from incident investigation, there must be organisation-wide support 2 Analysing problems Using and effect diagram) Chapter 27 gives an example of a fishbone diagram in use. 日 QQ || / 16 Types of Errors Diagnostic Error or delay Failure to employ indicated tests Use of outmoded tests/therapy Failure to act on results Treatment Error in performing procedure or test Error in administration of treatment Error in dose or method of using a drug Avoidable delay in treatment Providing care that is not indicated Other Failure of communication Equipment Failure Other System Failure Preventative Failure to provide prophylactic treatment Inadequate monitoring or follow up Leape, L. Lawthers, A., Brennan, T., Johnson, W. (1993). Preventing Medical Injury. Quality Review Bulletin 19(5), 144-149. E X 6 G 0 /16 บ Root Cause Analysis Find Out……. What happened? Why did it happen? How can it be prevented from happening again? Root Causes of Sentinal Events 2004-2015 http://www.psnet.ahrg.gov/primer.aspx?primerlD=10 Systems Analysis RCA seeks to identify the “holes” 1 Failure: Two patients with similar names are admitted 2 Failure: The patients are placed in rooms next to each other Hazards Losses 3 Failure: Drug orders are left at the nursing station by the doctor who is seeing both patients 4 Error: The patients are both discharged in the lunch hour and their medical orders are mixed up National Council of State Boards of Nursing, Inc. (20
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