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Quality Directions Australia 2003 1
Improving clinical risk management systems:
Root Cause Analysis
Quality Directions Australia 2003 2
Investigating adverse events
What often happens when we carry out these investigations: Inconsistent approaches Done by management All issues not explored Focuses on who did it rather than what went wrong Incomplete solutions No organisational learning
Quality Directions Australia 2003 3
Getting to the root cause
Arriving at the right answer is dependent on: Asking the right questions Asking the right people Asking in the right way Using the right time frame
Quality Directions Australia 2003 4
Getting to the root cause
A structured systems approach ensures: You are clear about the problem or event The people involved in the problem/event are
part of the process All steps in the process are carried out in the
right order Actions are put in place and evaluated
Quality Directions Australia 2003 5
Getting to the root cause
Root Cause Analysis (RCA) is: A structured approach aimed at getting
to the root cause of a sentinel (adverse) event, with the right people, using a specified process and leading to the outcome of an achievable risk reduction plan
Used to uncover failures of systems design
Quality Directions Australia 2003 6
The RCA Process
Describe the event Organise the RCA team Clarify the process leading to the adverse event Understand the causes of variation Select risk reduction strategies Go through the PDCA cycle (Plan/Do/Check/
Act)
Quality Directions Australia 2003 7
The RCA Process
Describe the adverse event:The event needs to be very clearly
described with no emotive terms- as a statement of the facts
Watch for elements of bias or assumptionThe date/ time and place of the event must
be clearly specified
Quality Directions Australia 2003 8
The RCA Process
Organise the team: RCA must be carried out by an appropriate team Team members should include all of those involved
in the event Team members should include people able to
authorise change The process must be clarified with the team at the
outset and appropriate ground rules set An external person can be useful to challenge
assumptions/ biases
Quality Directions Australia 2003 9
The RCA Process
Clarify understanding of the event: Includes process and causes of variation Tools should be used to assist in clarification Useful tools are:
Flowcharting to record the sequence of events Cause and effect diagrams to elucidate all contributory
factors Why/why and to dig down to root causes Affinity diagramming to categorise factors
Quality Directions Australia 2003 10
The RCA Process
Understanding causes of variation: Use multiple investigators to minimise bias Examine relevant documents Conduct structured interviews Field observation
No solutions!!
Quality Directions Australia 2003 11
The RCA Process
Select risk reduction strategiesDetermine which of the risks is most urgent
using a risk stratification toolDevelop a list of action items in terms of
urgencyUse a how/ how diagram to develop action
stepsDevelop evaluation measures for each of the
items
Quality Directions Australia 2003 12
The RCA Process
Go through the PDCA cyclePlan the improvementDo the improvementCheck the effectiveness of the
improvementAct to hold the gain ( policies/
procedures/ education/ongoing evaluation)
Quality Directions Australia 2003 13
Preparation for RCA
Have a group of staff trained in the process
Notify all relevant staff ASAP after a sentinel event has occurred
Appoint RCA team membersPrepare for first team meetingGo through the processDisseminate the action plan
Quality Directions Australia 2003 14
Using RCA for the case study
Describing the event As per case study – Transfer of
responsibility
Quality Directions Australia 2003 15
Using RCA for the case study
Organising the team DON or DMS of Hospital a to chair ADON A ADON B Receptionist Manager Clinical Risk Manager A to facilitate (Taxi driver)
Quality Directions Australia 2003 16
Using RCA for the case study
Clarifying the process Flow charting
Decision to transfer A to B/ communication with Hospital B/ booking for transfer accepted by ADON B with delivery to ED/ taxi booked by Hospital A/ Verbal instructions for driver/ patient delivered to reception at Hospital B/ receptionist confirms patient expected/ patient directed to ward / patient and taxi driver walk to ward/ patient falls at ward entrance and fractures hip
Quality Directions Australia 2003 17
Flow charting
Decision to transfer Communication with
hospital B Booking accepted by
ADON B Patient delivery to ED
organised Taxi booked by hospital A
How did communication occur? Was communication between
appropriate people? How was transfer assessed? Does a written procedure exist? What instructions were given? Why was patient to go to ED? Is a taxi transfer appropriate? What information was provided
to the driver?
Quality Directions Australia 2003 18
Transfer of Responsibility
Equipment
Procedures People
Policies
Patient fall
Causes Effect
Fishbone Diagram
Quality Directions Australia 2003 19
Transfer of responsibility
why did reception send man to ward?
no one to ask no contingency instructions not adequately trained
poor processes assumptions
no process
no/ inadequate policy lack of supervision
poor processes
Quality Directions Australia 2003 20
Using RCA for the case study
Understanding the causes of variation Communication between Hospital A and B Communication between Hospital A and taxi
service Reception processes at Hospital B Admission policies at Hospital B
Quality Directions Australia 2003 21
Using RCA for the case study
Selecting risk reduction strategies Development of transfer policies between
Hospitals A and B ( to include use of taxis) Development of admission policies at Hospital
B Education of reception staff at Hospital B
Quality Directions Australia 2003 22
Transfer of responsibility
How do we develop an appropriate transfer policy?
establish an appropriate team communicate with the taxi company
How do we do this?
identify person to communicate with
How do we do this?
identify all key players in the process
How do we do this?
flow chart the process
How do we do this?
P- Plan the improvement
Quality Directions Australia 2003 23
Using RCA for the case study
D-Institute the changes ensure that staff are educated on the changes
C- Check effectiveness of actionsCarry out relevant audits to ensure this is working make further changes if necessary
Quality Directions Australia 2003 24
Using RCA for the case study
A- Act to hold the gain Promulgate the new procedures Continue to educate staff Evaluate at regular intervals Go through the PDCA cycle again if necessary
Quality Directions Australia 2003 25
Limitations of RCA
Impossible to know if the root cause established by the analysis is the actual cause of the incident
May be tainted by hindsight bias May be bias relating to prevailing concerns in
the organisation Time consuming and labour intensive Qualitative rather than quantitative
Quality Directions Australia 2003 26
When to use RCA
Needs to be used where there are systems issues and where the establishment of barriers is likely to prevent such errors recurring
When assessing the adverse event, need to identify if there are a number of things that went wrong as distinct from the proximal cause
Need to determine if prevention of the event occurring could have happened at many stages in the process, not just one poor action
Need to be able to distinguish between clinical complexity (difficult to control) and systems complexity (controllable)
Quality Directions Australia 2003 27
Use of RCA
In the USA where RCA has been used consistently in the VHA for 10 months:
Events reported have increased by 30 times
Near misses reported have increased by 900 times
Near misses make up over 90% of events reported
Quality Directions Australia 2003 28
Keys to successful RCA
Selecting the right teamHaving a team with some knowledge of
the process- why/what/ howUsing a facilitator trained in the process,
tools and facilitation techniquesPractice the technique frequently to
maintain skills
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