Root Cause Analysis Day Course - Handouts

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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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!

Documents

Root Cause Analysis Day Course - Handouts