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Root Cause Analysis Theory and Practical Application of adverse event investigations. MG Schoon. Definition. Any event in the chain of causes that, when acted upon by a solution, prevents the problem from recurring. Purpose Identify causative factors and develop corrective strategies

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Root Cause Analysis Theory and Practical Application of adverse event investigations


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root cause analysis theory and practical application of adverse event investigations

Root Cause Analysis Theory and Practical Application of adverse event investigations

MG Schoon

definition
Definition
  • Any event in the chain of causes that, when acted upon by a solution, prevents the problem from recurring.

Purpose

  • Identify causative factors and develop corrective strategies
  • To prevent adverse events/outcomes
  • Prevent harm
  • Improve quality care and patient safety
near miss
Near miss
  • A patient safety incident that did not cause harm
  • Near miss in pregnancy

Adverse outcome that did not result in death

patient safety prevention improvement tools
PATIENT SAFETY PREVENTION/ IMPROVEMENT TOOLS

Patient satisfaction survey

Patient complaints

Adverse events assessments

Dashboards/ trend analysis (trigger tools)

Clinical audits

Clinical case reviews

Clinical guidelines & protocols

Checklists

Fire drills/ simulation exercises

patient safety culture
Patient safety culture

Patient safety is everybody’s business 

root cause analysis
ROOT CAUSE ANALYSIS

An effective tool for systematically identifying problems and analysing critical incidents to generate

systems improvements

root cause analysis1
ROOT CAUSE ANALYSIS

Find out:

  • What happened
  • Why did it happen
  • What can be done to reduce the likelihood of a recurrence
cases that should not be subjected to rca
Cases that should not be subjected to RCA

Events thought to be the result of a criminal act

Purposefully unsafe acts (intended to cause harm)

Acts related to substance abuse

Events involving suspected patient abuse of any kind

strong support from upper management
Strong support from upper management

It must be accepted that results of any given root cause analysis will be for improving situations, not for assigning blame

Berry & Krizek

slide12
RCA

1. is inter-disciplinary, involving experts from the frontline services;

2. involves those who are the most familiar with the situation;

3. continually digs deeper by asking why, why, why at each level of cause and effect;

4. identifies changes that need to be made to systems; and

5. is as impartial as possible in order to make clear the need to be aware of and sensitive to potential conflicts of interest

slide13

Success depends on involvement of the attending physician, consulting specialist and other providers

check for eligibility for rca
Check for eligibility for RCA
  • Deliberate harm test
    • whether the actionswere as intended, not whether the outcomewas as intended
  • Incapacity test
    • Was a staff member ill or intoxicated
  • Foresight test
    • Did the individual depart from agreed protocols or safe procedures?
  • Substitution test
    • Would another individual coming from the same professional group, possessing comparable qualifications and experience, behave in the same way in similar circumstances?
rca steps
RCA Steps

Collect information

Causal factor charting

Root cause identification

Recommendations

overview of rca process
Overview of RCA Process

AE occurs

Evaluate

Implement corrective action plan

Patient safety reporting system ie Aims call centre 6262/6464

Initiate and complete RCA

RCA required ?

SAC rating

YES

NO

No further action required

collect information
Collect information
  • Gather information already documented
  • Review health records
  • Flow chart/ timeline
  • Get additional information
    • Site visit
    • Interviews
map timeline chain of events
Map timeline-chain of events

Kitchen burn

Mary fry chicken in pan

Fire spread

Mary leave pan unattended

Throw water in pan

Fire start on stove

Mary come back – get fire extinguisher

Fire extinguisher does not work

causal factor charting
Causal factor charting

Kitchen burn

Mary fry chicken in pan

Fire spread

Mary leave pan unattended

Throw water in pan

Fire start on stove

Mary come back – get fire extinguisher

Electric burner short

Melt hole in pan

Oil leak and ignite

Fire extinguisher does not work

causal factor charting1
Causal factor charting

Kitchen burn

Mary fry chicken in pan

Fire spread

Mary leave pan unattended

Throw water in pan

CF

CF

Fire start on stove

Mary come back – get fire extinguisher

Electric burner short

Melt hole in pan

Oil leak and ignite

Fire extinguisher does not work

CF

CF

slide21

Knowing what adverse events occur is only the first step. Most adverse events result from a complex series of behaviours and failures in systems of care. Investigation of the patterns of adverse events requires unearthing the latent conditions and systemic flaws as well as the specific actions that contributed to these outcomes.

Dr. G. Ross Baker & Dr. Peter Norton

swiss cheese model
Swiss cheese model

most accidents can be traced to one or more of four levels of failure

  • Organizational influences,
  • unsafe supervision,
  • preconditions for unsafe acts, and
  • the unsafe acts themselves.
root cause identification
Root cause identification

Do Root cause mapping of causal factors

ishikawa diagrams
Ishikawa diagrams

Personnel

Measurements

Materials

Environment

Methods

Equipment

ishikawa diagrams1
Ishikawa diagrams

Personnel

Measurements

Materials

Shifts

Alloys

Callibration

Training

Lubricants

Microscopes

Suppliers

Operators

Inspections

Angle

Wear

Humidity

Callibration

Speed

Temperature

Callibration

Callibration

Environment

Methods

Equipment

causal factor charting2
Causal factor charting

Was that policy in use/known to mary?

Kitchen burn

Was there a policy regarding phone use in the kichen?

Mary fry chicken in pan

Fire spread

Why did she answer the phone

Mary leave pan unattended

Why did mary leave the pan unattended?

Throw water in pan

CF

CF

Fire start on stove

Mary come back – get fire extinguisher

Electric burner short

Melt hole in pan

Oil leak and ignite

Fire extinguisher does not work

CF

CF

causal factor charting3
Causal factor charting

Kitchen burn

Was the policy adhered to?

Mary fry chicken in pan

Is there a replacement policy?

Fire spread

Was the burner checked/ serviced?

Mary leave pan unattended

Throw water in pan

Why did the electric burner short?

CF

CF

Fire start on stove

Mary come back – get fire extinguisher

Electric burner short

Melt hole in pan

Oil leak and ignite

Fire extinguisher does not work

CF

CF

causal factor charting4
Causal factor charting

Kitchen burn

Is fire drills done to practice fire emergency procedures?

Mary fry chicken in pan

Was Mary trained on the use of Fire extinguisher?

Fire spread

Was the fire extinguisher checked/ serviced?

Mary leave pan unattended

Throw water in pan

Why did the fire extinguisher not work?

CF

CF

Fire start on stove

Mary come back – get fire extinguisher

Electric burner short

Melt hole in pan

Oil leak and ignite

Fire extinguisher does not work

CF

CF

causal factor charting5
Causal factor charting

Kitchen burn

Mary fry chicken in pan

Fire spread

Was the fire brigade called?

Did whe call for help? Why Not?

Mary leave pan unattended

Throw water in pan

Did Mary know how to extinguish an oil fire?

CF

CF

Fire start on stove

Mary come back – get fire extinguisher

Electric burner short

Melt hole in pan

Oil leak and ignite

Fire extinguisher does not work

CF

CF

recommendations
Recommendations

List the recommendations

Write a report regarding the findings

Suggest some implementation strategies

rca thoroughness
RCA Thoroughness

1. an understanding of how humans interact with their environment;

2. identification of potential problems related to processes and systems;

3. analysis of underlying cause and effect systems through a series of why questions;

4. identification of risks and their potential contributions to the event;

5. development of actions aimed at improving processes and systems;

6. measurement and evaluation of implementation of these actions; and

7. documentation of all steps (from the point of identification to the process of evaluation).

rca credibility
RCA credibility

1. include participation by the leadership of the organization and those most closely involved in the processes and systems;

2. be applied consistently according to organizational policy/procedure; and

3. include consideration of relevant literature.

root cause analysis techniques
Root cause analysis techniques

Re-enactment ( computer or a simulator)

Comparative re-enactment

Re-construction-reassembling

Barrier analysis

Bayesian inference

Change analysis -

comparing the way an episode did happen with the way it was intended to happen.

Current Reality Tree 

Failure mode and effects analysis

Fault tree analysis

Five whys 

Ishikawa diagrams 

Why-Because analysis 

Pareto analysis "80/20 rule"

RPR Problem Diagnosis -

Kepner-Tregoe Approach

PROACT Approach 

Project Management Approaches.

use of training to reduce errors
USE of training to reduce errors

Training

Too Little

inaccuracy

Training

Optimal

prevent

errors

Training

Too much

Inefficiency

the institute of medicine s six elements of quality
The Institute of Medicine’s Six Elements of Quality

1. Patient safety. Are the risks of injury minimal for patients in the health system?

2. Effectiveness. Is the care provided scientifically sound and neither underused nor overused?

3. Patient centeredness. Is patient care being provided in a way that is respectful and responsive to a patient’s preferences, needs, and values? Are patient values guiding clinical decisions?

4. Timeliness. Are delays and waiting times minimized?

5. Efficiency. Is waste of equipment, supplies, ideas, and energy minimized?

6. Equity. Is care consistent across gender, ethnic, geographic, and socioeconomic lines?

Source: Institute of Medicine 2001.

summary
SUMMARY

Investigation:

The investigation takes place where the event took place.

Get sufficient information by:

Studying all relevant documents

Obtaining reports and/or sworn statements

Conducting interviews with complainant/patient/family and staff, as well as supervisors/management

Doing observations

Brainstorming sessions

Determine cause of adverse event

Determine whether precautionary and corrective measures are in place

Write full report with recommendations to Management and DAEC/PAEC

disclosure rationalisation
Disclosure & Rationalisation

Disclosure to non-physicians

Disclosure to physicians

Disclosure to patients

Disclosure to facility

Rationalisation to cover-up