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
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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)
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
What is a Root Cause?
What is Root Cause Analysis?
To be thorough RCAmust involve a complete review of all possible antecedent events and actions
To be credible a root cause analysis must:
To be effective a root cause analysis must :
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 personnelTwo Views On Human Error
Violations involve deliberate deviations from some regulated code of practice or procedure, Reason (1993). They occur because people intentionally break the rules.
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’
Can you think of one instance where you have made:
J. T Reason, 2001
The Jack and Jill story
Identify what happened and antecedents
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.
Depicts events sequence in simple, easy to read
What were they doing over a 20 minute period in the busy A+E Department
Who would you want/expect to investigate this case?
What is the extent of your investigation?
(Based on the AS/NZS 4360:1999 Risk Management Standard)
I have just been given a parking ticket
Parked in a 10 minute max parking zone and time expired
Held up in a queue at the local bakery
The till was inoperative
Till had not been serviced by manufacturers
Bakery had forgotten to extend maintenance contract
Education and Training factors
Equipment and resource factors
Working condition factors
Organizational and strategic factors
The Action Plan
Make mistakes impossible
Remember redesign means new Risks. Solving a problem in one area may create a new problem in another
(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)
Thank you for listening!