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8/6/2019 Root Cause Analysis Day Course - Handouts
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Effective Event Analysis
Using Root Cause Analysis
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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 arenot embedded in practice
Organisation with a memory 2002
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Person-centred approach Systems approach
Individuals who makeerrors
are careless, at fault,
reckless
Poor organisational designsets people up to fail
Blame and punish Focus on the system rather
than the individual
Remove individual
= improve safety
Change the system
= improve safety
Understanding adverse incident causes
which approach will make it safer?
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A safety culture is.
A culture where staff have a constant andactive awareness of the potential for things
to go wrong
A culture that is open and fair, and one that
encourages people to speak up aboutmistakes
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Rasmussens 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
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Situations
Routine
Trained for Problem
Novel Problem
Control Methods
Conscious Mixed Automatic
Knowledge
based
Rule based
Skill Based
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Errors
An error is the failure of planned actions toachieve their desired goal, where this occurs
without some unforeseeable or chance
intervention Reason 1990
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Types of ErrorSlip, trip, lapse, fumble
The plan is correct but the action fails ( failure of
action or memory)
Recognition Failures
Problem detection Failure
Memory Failure
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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.
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Violations
Routine Violations
Deliberate deviations from accepted codes of practice. Used toavoid 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
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Violations
Reckless
Deviation from the protocol where damage can be easilyforeseen and ignored although no harm is intended.
Malicious
Where there is an intention to cause harm - Shipman, Alitt
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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 ofthe systems in which people work. More often thannot, a single error has multiple sources. Reducingerrors also will require us to design and implementmore error-resistant systems.
Gordon Spencer
President & CEO American Hospital Association
Quoted in Building a Safer NHS forPatients 2001
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Root Cause
The most basic reason for a problem,which, if corrected, will prevent
recurrence of that problem Ammerman 1998
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Process of Effective IncidentInvestigation
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
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Process Analysis Causal Factors
Decide on Options forImprovement
Provide report
Ensure implementation ofImprovement
Plans
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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
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Why dont 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
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Trust Policies
Operational Policy and Procedure forreporting and management of accidentsand incidents.
Incidents, accidents and the Trust
disciplinary process- Guidelines formanagers, Clinical Directors andemployees
Disciplinary
Action
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Near Misses An opportunity to improve environmental,
health and safety practice based on acondition, 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 anincident, accident or other serious performanceproblem but did not because of one or moresafeguards or other factors (such as luck).
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REPORTED NEAR MI E
pace huttle Challenger 1986.
y 7 Killed.
y Engineers had reported degradation in O ring sealers
dating back to 1982
y The night before management had been warned that ifambient temperature was below 36 degrees disaster wouldfollow.
The Hindustan Refinery 1997
y 60 People Died10,000 metric tons of petroleum based
products released into airy Written complaints of corroded and weakened transfer
lines ignored
The Morton Reactor Explosion 1998
y 9 Serious Injuries
y Management failed to identify warnings of excessivetemperature reports
The Paddington Disaster 1999
y 31 People Died
y From 1993 1999 eight near misses or signals passed atdanger (SPADS) had occurred at that location (Signal109) one of 22 with the greatest number of failures.
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Support Staff and Patients Being Open Policy
Supporting staff when things go wrong
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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
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Collecting Information Physical Evidence
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Collecting Information
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Collecting Information
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Cause and Event Charting
Event and Causal factor charting is an analysis
tool whereby you chart the relationship ofevents, conditions, changes, barriers and
causal factors on a timeline
Used when Equipment fails
Human actions cause problems
Barriers fail
Many factors are evident
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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
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Cause & Effect ChartingE V E N T H A R TI & c i ' e & t
T ( e m o s t s e r i o ) s e v e & t t o o k 0 l a c e
T ( e r e a s o & f o r t ( e i & v e s t i g a t i o &
E & c l o s e ' i & a c i r c l e a& '
c o& &
e c t e ' 1 y a & a r r o 2
E v e & t
E a c ( B o x i s a s t e 0 i & t ( e s e q ) e & c e o & e a c t i o &
0 e r 1 o x
W ( a t ' i ' 2 ( a t o r 2 ( o ' i ' 2 ( a t
3
s e j o1
t i t l e s&
o t&
a m e s
E v e & t E v e & t s i & ' a s ( e ' 1 o x e s a r e y e t t o 1 e 0 r o v e &
4 o & ' i t i o & sE x 0 l a i & t ( e a c t i o & s t ( a t t o o k 0 l a c e i & a &
a t t a c ( e ' 1 o x
F a c t ) a l a& '
N o & J) '
g e m e & t a l
4 o& '
i t i o & s4 o & ' i t i o & s y e t t o 1 e c o & f ir m e ' r o o m f o r
f) r t ( e r q ) e s t i o & s
4 a ) s a l F a c t o r t o 1 e a t t a c ( e ' t o
c o& '
i t i o &
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Example - Cause and EffectChart
1/2/3 14.00hrs
Patient leavesWard
18main entrance
Pt.5
alks
onto5
et
corridor
No 5
et floor
signs in place
6
omestic notreminded to put out
5
et floor si ns
Washes5
hole5
idth ofcorridor no dry space
for5
alking
Patient slips
and injures
back
Taken to Accident and7
mergency for
treatment
6
omestic not trained to5
ash corridors in strips
1/2/3/ 13.506
omestic Assistantstart
5
ashing main
Corridor Floor
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Chart the Event - Mr Charlton
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Mr arlto - Age 41yrs
19/3/008
atient undergoes surgery9
or repair o9
hiatus hernia
22/3/00
-8
t complains o9
chest
pain
8
ain attributed to
post op soreness
@
o9
urther tests
carried out
@
o policy9
or post
op testing9
or
chest ain
SHOBeen on
call9
or 3days
24/3/008
t complains o9
pain to nurse
@
urse newly quali9
ied
not trained in spotting
postoperative
problems
On thejobtraining
provided as
andwhen
@
ursedoesnt
in9
orm anyone
senior o9
chest
pain
26/3/008
atient
discharged9
romCity
Hospital
27/3/008
t visits G8
8
t. Decides to go to
County Hospital
A/E Dept
A
A
Pt dissatis9
ied
with City
Hospital
Investigations
carried out at
County Hospital
Leaking suture line9
ound to have
caused
in9
lammation and
damage to le9
t lung
29/3/00
Remedial surgery carried
out atCounty Hospital
21/3/01
Patient9
iles
claim9
or
malpractice
Patient re9
erred
back toCity
Hospital
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50
TBR
EVEA
T
PerceivedBy witness
EveB
t factors
y Distance
y Lighting
y Violence/ Weapon
y Length oC
observation
WitD
ess factors
y Stress
y Alcohol
y Drugs
y Selective Attention
y Witness Involvement
Stored memory
Recalled Event
Interviewee
y InE
erences
y Stereotypes
y Partisanship
y Scripts
INTERVIEW
Post event inF
ormation, delay,instructionsF
or
response and questioning methods
Reported
Event
Perceived
ReportInterviewer
y InterviewingGuidelines
y Predetermined
Hypotheses
y Questioning
strategy
y Schema
y Frame oG
ReG
erence
StoredReport
Recalled
Report
Record oG
Event
Memory T eory & I tervie Process (Kohnken 1995)
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Interviewing Information is the Lifeblood of an
Investigation
Witness information is critical to an effectiveinvestigation
Memory is fragile and can be influenced
Poor questioning technique will lead to errors
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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 tocover
Carry out the interview around 72 hours Have interview checklist ready
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Interviewing - Practice Personalise the interview - introduce
yourself and guest and explain purpose ofthe exercise
Emphasise the fact finding nature of theinterview no fault
Tell interviewee how the information will
be used explain what is expected of theinterviewee
Transfer of control
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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 Interviewees state of mind
Open v Closed questions
Concentrate on what was as fault, not whowas at fault
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Interviewing
Ask what they
Did? Saw?
Heard?
Smelled?
Review the incident on the flip chart/white board
Clarify each event if required
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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 rememberanything else relating to the incident givethem your telephone number or card
Record the interview Assist with statements if required
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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)
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Interviewing - Do not
Forget staff may create information. Watchfor signs of lying or stress.
Allow pre-conceptions to cloud judgement
Use negative phraseology
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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
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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
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Walk Through Task AnalysisPurpose: - To simulate the task being performed. Staffs are requested to demonstrate the 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
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TASK ANALYSIS
Step WHO Required Action Component Tools Remarks/Questions
1 Driver Ensures that weekly checks
and regular services has been
carried out
If driver does not know
car then s/he should
look for service manual
and re- check
according to
manufacturersinstruction book
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.
Tyre pressure should
be checked weekly with
water and oil checks
4 Driver Unlocks car Drivers side door lock Key / Fob press button A
see diagram Disengages alarm alldoor unlocked
5
Driver Removes Key if key is used Door lock
6
Driver Opens car door by pulling
handle upwards
Door handle Handle spring loaded
will return to place
Task to be Analysed STARTING THE CAR
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Step WHO Required Action Component Tools Remarks/Questions
7 Driver Enters cabin and sits indrivers seat and closes
door
Drivers seat Left leg firstbalancing on right
leg. Steadies
him/herself with left
hand on steering
wheel to pull in right
leg
8 Driver Attains comfortable
position with both feet in
foot well
Drivers seat.
9Driver Checks visibility of all
windows and mirrorsWill leave car and
clean car windows if
visibility is restricted
10 Driver Checks that all lights are
working
Lights front full,
dipped and drake
Light switch May need assistance
to check rear brake
lights
11 Driver Checks that the car is in
neutral
Gear lever Wiggles it to ensure
it is not engaged
12 Driver Checks that hand brake is
engaged
Hand brake lever Pulls upwards until
it can move no
further and is lockedin position
13 Driver Releases seat belt Seat belt Reaches with left
hand over right
shoulder to pull
seatbelt downwards
and to the left
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WHY ANALYSIS
Follow path o questions asking the rhetorical question Why Descend ive levels or until theRootCause is Found
IH
CRESIH
G
LEVELSOF
COMPLAIH
TS
FROM
PATIEH
TS
ABOUT
WARD 2
MEALSGIVEH
OUTCOLD
MEDICATION
ERRORS
STAFFBRUSQUE
AND UNHELPFUL
MEAL TROLLEYS
INADEQUATE FOR
DEMAND
NO-ONE DEDICATED
TO GIVING OUTMEALS
NOPLANNING FOR
REPLACEMENT WHEN
OBSOLETE
UNDERSTAFFING
NO
MANAGEMENT
SYSTEMFOR
CONTROLOF
EQUIPMENT
NORE-PROFILING
EXERCISE CARRIED
OUT
POORLYWRITTEN
PRESCRIPTIONS
NOAUDITOFQUALITY
OFPRESCRIPTIONS
NOPOLICY TO
MEASURE AGAINST
NOT THOUGHT
NEEDED
NOMANAGEMENT
SYSTEMFOR
QUALITY
UNDERSTAFFING
NOTRAINING INQUALITY
SERVICES
NORE-PROFILING
EXERCISE
NOT THOUGHT
NEEDED
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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
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Types ofBarrier 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
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Performing a Barrier Analysis Identify issue to be analysed from Cause and
Effect chart
B
rainstorm hazards, barriers and targets for theissue. Use appropriate experts if required.
Consider the Hazards to Targets under the
following headings: - People (Safety hazards)
Property
A productivity and profit
Environment
Quality
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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
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Change Analysis
Principle:_
When a task, process or machine has
worked effectively and then fails
something must have changed to causethe problem
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Change Analysis - used when Equipment that has operated well in the past startsto 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
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Change Analysis - Process Identify the factors that InfluencePerformance
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 thedifference caused the problem.
Add this information to the Cause and Effect Chart
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Change Analysis - workedexample Mr Smith, 64yrs. steel worker, was
scheduled for amputation of right leg due
to circulatory problems caused bydiabetes. There were problems with the
left leg that would probably result in
amputation at a later date. After surgery itwas discovered that the wrong leg had
been amputated.
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Change Analysis - Factors forselection
Factors that would influence the selection of thecorrect limb:-
The surgeons knowledge of the patients condition Expectation that the operation site would be damaged
The medical record and consent form should identify the areaof 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 theywork correctly and have the correct leg draped
Factors that Interview When Correct When wrong Did
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Factors that
Influence Leg
selection
Interview
Questions
When Correct
leg is selected
When wrong
leg is selected
Chan Did
change
influence
selection
Knowledge ofPatient
Tell us aboutknowledge of this
patient comparedwith other
patients you have
operated on?
Knowledgeable Same No
Theatre List Was the legidentified on thetheatre list?Did you
personally reviewthe list prior tocommencementof list?
Correctinformation
List reviewed by
authorisingsurgeon
List changed atlast minute. Newhand written list
provided which
was not checked by surgeon
Yes Yes
Marking of site Were markingused to denotecorrect site andchecked againstmedical records?
Skin pencil usedto apply X to legafter checkingwith medicalrecords
Biro used tomake X as
patient crossedhis leg the markrubbed on to the
other leg
Yes Yes
Knowledge of
other teammembers
Did members of
the team indicatewhich leg was to
be amputated?
Correct leg
draped
Incorrect leg
draped
Yes Yes
Surgical sitepreparation
Who prepared theleg. Were drapes
used|? Anythingabnormal?
Standard pre bysurgical
assistant
Surgicalassistant got
informationfrom revised list
Carried out precorrectly
Yes Yes
Fatigue Ask about hours
on duty andalertness prior to
procedure?
Normal Normal No
Expectations Did you hav e an yexpectations thatmay haveinfluenced your
selection of thelimb to amputate?
Expect toamputate adiseased limb
Draped limb wasdiseased
No
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Changes that Contributed to theProblem 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 andconsent form
Draping not carried out by surgeon who knew the
patient
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DEVELOPING CORRECTIVEACTIONS
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.
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Evaluation OfAlternatives Consider Will the corrective action(s) prevent reoccurrence of the
problem?
Is the corrective action within the capability of theOrganisation to implement?
Does the corrective action meet the Trusts 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
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Countermeasure MatrixScore the Effectiveness and feasibility in rate from 1 5;
1 being low and five high. Multiply the two scores to
give overall ratingPROBLEM ROOT
C USE
C ounterm easure easibility E ffectiveness Overall ction
1)
2)
3)
4)
5)
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Consider ways of monitoring theEffectiveness 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
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Report Content
Terms of reference
Demographic details of patient and synopsis ofincident
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
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Where to now!