Root cause analysis

1. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Posted for FRCS vivaPosted for FRCS viva
preparationpreparation
Rish SharmaRish Sharma
srishabha@gmail.comsrishabha@gmail.com

2. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Getting started
Organisations should have a formal written procedure for ‘commissioning’
RCA investigations: It typically includes...
1. Definition and classification of incidents
2. Which incidents need RCA (Triggers and proportionality)
3. Membership of investigation team and support
4. Guidance on Terms of Reference
5. Timescale guides
6. Framework for report
7. Involvement of patient and family
8. Involvement of staff
9. Investigative interviews for learning
10. Contact with media
11. Legal advice/police/HSE
12. Link with board

3. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Triggers For Investigation
Which PSI requires an RCA?
•Frequently occurring PSI / Prevented PSI
•Bacteraemias
•Incidents that have previously been the subject of an Alert
•PSI causing death or severe harm (serious incidents)
•‘Never Events’

4. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Never Events
17 new additions from Feb. 2011
1. Wrong site surgery
2. Wrong implant/prosthesis
3. Retained foreign object post-operation
4. Wrongly prepared high-risk injectable medication
5. Maladministration of potassium-containing solutions
6. Wrong route administration of chemotherapy
7. Wrong route administration of oral/enteral treatment
8. Intravenous administration of epidural medication
9. Maladministration of Insulin
10.Overdose of midazolam during conscious sedation
11.Opioid overdose of an opioid-naïve patient
12.Inappropriate administration of daily oral methotrexate
13.Suicide using non-collapsible rails
14.Escape of a transferred prisoner
15.Falls from unrestricted windows
16.Entrapment in bedrails
17.Transfusion of ABO-incompatible blood components
18.Transplantation of ABO or HLA-incompatible Organs
19. Misplaced naso- or oro-gastric tubes
20. Wrong gas administered
21. Failure to monitor & respond to oxygen
saturation
22. Air embolism
23. Misidentification of patients
24. Severe scalding of patients
25. Maternal death due to post partum
haemorrhage after elective Caesarean
section
www.dh.gov.uk and www.npsa.nhs.uk

5. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Gathering Information & Mapping the Incident
Identifying Care & Service Delivery Problems
Analysing Problems & Identifying CFs and RCs
Generating Solutions & Recommendations
Implementing Solutions
Writing the Report
Getting Started
The RCA Process

6. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Getting Started
1. Classify the Incident
2. Establish the core investigation team
3. Scope the incident

7. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Classifying incidents
• Use organisational procedure for PSI classification
• Classify according to:
• The degree of harm or damage caused at the time
• Its realistic future potential for harm if it occurred again
(required locally and for RCA but not for incident reporting to NPSA)

8. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
PATIENT SAFETY
INCIDENT
Any unintended or
unexpected incident(s)
which could have or
did lead to harm for
one or more persons
receiving NHS
funded care
NO HARM
LOW
MODERATE
SEVERE
DEATH
Not prevented,
but resulted in
no harm
Prevented,
not impacted on
patient
NPSA definitions
Good Catch
Good Luck!

9. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Selecting the RCA investigation team
• Core multidisciplinary team of 2-3 people
• One of which should be fully trained in incident investigation
• Good organisational skills
• Appropriate use of experts
For incidents with death or severe outcomes:

10. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
How the core team involve others

11. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Selecting the RCA investigation team
Near miss or less serious event investigations
(high frequency)
• Can be undertaken by one person e.g. ward manager
• Can be a useful learning process for clinical teams

12. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Level and Scope of RCA
What level of investigation is required?
Level 1 - Concise investigation
Level 2 - Comprehensive investigation
Level 3 - Independent investigation
Where would you plan to start and finish the RCA?
- Need full Terms of Reference for Serious incident investigations

13. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Level 1 - Concise investigation
• Used for ‘No, Low or Moderate Harm’ incidents, claims, complaints or concerns
• Commonly involves completion of a summary or ‘one page’ structured template
• Conducted by one or more people local to the incident (ward / dept / GP surgery)
Level 2 - Comprehensive investigation
• For actual or potential ‘Severe or Death’ PSI outcomes
• Conducted to a high level of detail
• Conducted by a multidisciplinary team, or involves expert opinion / independent advice
• Conducted by staff not involved in incident, locality or directorate in which it occurred
• Overseen by a director level chair or facilitator
Level 3 - Independent investigation As per the above ‘Level 2 but…
• Must be Commissioned and Conducted by those independent to the organisation involved
• For incidents of high public interest or attracting media attention
• For Mental Health Homicides defined by Department of Health guidance in England
(Healthcare Inspectorate Wales (HAW) are commissioned to carry out Homicide reviews in
Wales)
www.npsa.nhs.uk/rca
Levels of RCA Investigation

14. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
www.npsa.nhs.uk/rca

15. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Examples of Concise Investigation Reports
www.npsa.nhs.uk/rca

16. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
An option for concise investigations...
Consider Multi-incident Investigations - With narrow themes
www.npsa.nhs.uk/rca

17. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Exclusions to RCA Investigations
conducted for learning purposes
Escalate or hand over the investigation of:
1. People thought to be involved in a criminal act
2. Those involved in purposefully unsafe acts (where a care
provider intended to cause harm by their actions)
3. Acts related to substance abuse by provider/staff
4. Acts involving suspected patient abuse of any kind
Canadian root cause analysis framework

18. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Getting Started - GROUP WORK
With reference to your case study…
1. Classify the Incident
• What is the actual severity (actual degree of harm
caused)?
• What is the realistic severity and likelihood of a
recurrence?
• Is an investigation required?
2. Establish the core investigation team?
• Who should be on the core team?
• What expert advice is needed?
3. Scope the incident
• Where should you start and finish?
• What level of investigation is required?

19. Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Key Points - Getting started
Good investigations begin with good planning
 Select the most appropriate level of Investigation
(Independent, Comprehensive, Concise or Multi-incident)
 Set (and keep to) clear terms of reference and timescales
 Enlist appropriate authority to investigate and effect change