Root cause analysisSlides adapted from:

• the proceedings of the first workshop of Leadership mentorship for Maternal, Newborn and Child health: a programme for DCSTs in KwaZulu-Natal , 13 to 17

August 2012.KZN DOH/UNICEF/UKZN.

• A presentation given by Dr MG Schoon, Department of Health, Free State Provence

DefinitionPurpose

Identify causative factors and develop corrective strategies

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

To prevent adverse events/outcomes

Prevent harm

Improve quality care and patient safety

Age distribution per age and sexNorth Cape

Namakwa

Access to piped water

Mortality 2010/2011 2011/2012

Maternal mortality ratio 239/100 000 live births 167/100 000 live births

Facility infant mortality rate

6.5/1000 live births 8.4/1000 live births

Under 5 mortality rate 5.3/1000 live births 5.5/1000 live births

N Cape maternal, infant and mortality rates

Top causes of maternal death in Gauteng

Non Pregnancy Related Infections 53.4%

Hypertension 22.7%

Haemorrhage 22.4%

Pre-existing medical conditions 12.7%

Pregnancy related sepsis 10.6%

Acute collapse 6.3%

Anaesthetic related 2.4%

Abortion 4.9%

NCCEMD 2012

Causes of under-5 mortality in SA

Diarrhoeal Disease 22%

Neonatal causes 15%

Acute respiratory infection 14%

HIV contributes to at least half of child deaths in SA

60% of deaths in the Child PIP are associated with malnutrition 10% of children 1-9 yrs underweight* 20% of children aged 1-9yrs stunted*

*National Food consumption survey in CoMMiC Report 2011

CoMMiC Report 2011

Root course analysis

An effective tool for systematically identifying

problems and analysing critical incidents to generate

systems improvements

WHY! WHY? Why……………

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

RCA1.It 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

Check for eligibility for RCADeliberate harm test

whether the actions were as intended, not whether the outcome was 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?

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

RCA (+as part of clinical audits):

Success depends on involvement of the attending

physician, consulting specialist and other providers

RCA steps

Collect information

Causal factor charting

Root cause identification

Recommendations

Process

Gather information already documented

Review health records

Flow chart/ timeline

Get additional informationSite visitInterviews

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.

Ishikawa diagramsMeasurements PersonnelMaterials

EquipmentMethodsEnvironment

Ishikawa diagramsMeasurements PersonnelMaterials

EquipmentMethodsEnvironment

Callibration

Microscopes

Inspections

Shifts

Training

OperatorsSuppliers

Lubricants

Alloys

Callibration

Speed

WearAngle

Callibration

Callibration

Humidity

Temperature

But why?Why are there so many maternal and child deaths associated with

HIV?

But why?

Assign the role of ‘devil’s advocate’ to someone in your tribe … “Devil's advocate role seeks to engage others in an argumentative

discussion process. The purpose of such process is typically to test the quality of the original argument.”

The responsibility of the Devil’s Advocate is to ask the question: ‘But … So why?'

http://en.wikipedia.org/wiki/Devil's_advocate

Identify themes/categories that the factors you have identified can fit into

How do these themes/categories relate to each other?

Draw a large picture to show your thinking

Root cause summary Causal factor # 1 Paths Through Root

Cause Map Recommendations

Mary leaves the frying chicken unattended.

• Personnel difficulty.• Administrative/ management systems.• Standards, policies or administrative controls (SPACs) less than adequate (LTA).• No SPACs.

• Implement a policy that hot oil is never left unattended on the stove.• Determine whether policies should be developed for other types of hazards in the facility to ensure they are not left unattended.• Modify the risk assessment process or procedure development process to addressrequirements for personnel attendance during process operations.

Root cause summary Causal factor # 2 Paths Through Root

Cause Map Recommendations

Description:Electric burner element fails (shorts out).

• Equipment difficulty.• Equipment reliability program problem.• Equipment reliability program design LTA.• No program.

• Replace all burners on stove.• Develop a preventive maintenance strategyto periodically replace the burner elements.• Consider alternative methods for preparing chicken that may involve fewer hazards, such as baking the chicken or purchasing the finished product from a supplier.

Recommendations List the recommendations

Write a report regarding the findings

Suggest some implementation strategies