Root Cause Analysis

Investigation Training

2 Day Lead Investigator

Programme
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 Introduction & Overview
Learning Outcomes
After attending this event, and using the knowledge, skills and
resources gained, delegates should be better able to:-

• Outline and discuss the theory underpinning RCA

Investigation
• Describe and promote effective investigation process
• Lead and conduct credible, thorough and proportionate
RCA Investigations
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 Resources
www.npsa.nhs.uk/rca

Content from National Patient Safety Agency material

http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 How many people are treated every day
in the NHS?

Over 1 million

Content from National Patient Safety Agency material

http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 Complexity of Healthcare

Number of Healthcare Diagnoses listed? > 68,000

Number of Healthcare Procedures available? > 6,000

Number of Healthcare Medications available? > 4,000

January 2010

Content from National Patient Safety Agency material

http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 Complexity of Healthcare

Healthcare has grown exponentially in its complexity

This has outstripped our ability to provide care safely

Dr Atul Gawande - 2009

Content from National Patient Safety Agency material

http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 Investigation of Incidents

Def: Patient Safety Incident (PSI)

Any unintended or unexpected incident(s)
that could have or did lead to harm for one or more
persons receiving NHS funded healthcare

RCA framework is also applicable for the investigation of:

• Claims
• Complaints
• Other types of incident (Clinical, non-clinical, social care etc)
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
NPSA - 2003
 Number of Patient Safety Incidents occurring
in the NHS each year?

Content from National Patient Safety Agency material

http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 Patient safety - A global issue
- True scale still unknown

18
16
Patient
Safety
14 USA 3.7%
Incidents/ 12 Australia 16.6%
Events
10 England 10.8%
8 Denmark 9%
6 New Zealand 12.9%
4 Canada 7.5%
2 Japan 11%
0
% of acute admissions
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 Hospital blunders 'kill 90,000 patients‘
Rebecca Smith: Daily Telegraph - 29.11.07

“More than 90,000 patients die

and almost one million are
harmed each year because of
hospital blunders, research
suggests” ?!

Researchers found that up to half of

the mistakes made were preventable
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 National Reporting and Learning System

Analysis
Tools
Data Cleansing

Local Incident
Reporting System National
Reporting &
Learning Reports &
Content from National Patient Safety Agency material System Trends
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 Systems thinking
Healthcare has focused extensively on getting the best kit
and the best technical expertise. £billions is spent on
medical discovery annually.
BUT
Only a handful of people are currently ‘doing the science’
- studying how best to fit it all together safely.
We need to make the complex simple, start small, and
gradually improve the quality of our systems.
From Dr Atul Gawande - 2009
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 Clinical Information: 08-09
• 66 million OPD appointments in UK (Excl. N Ireland)
• 10 million had important clinical information missing
• Patients were exposed to risk at 2 million appointments

Operating Theatre equipment

(?could be applied to any healthcare equipment?)

In nearly 1 in 5 operations:-
the equipment was faulty, missing or used incorrectly
– or staff did not know where it was or how to use it.
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ The Health Foundation - 2010
 There is a need to learn from patient safety incidents
... A systems view is needed
• Evidence from other complex high technology settings
suggests that systematic investigation of adverse
incidents can expose system failures.

• System failures can be the cause of human errors.

• Root Cause Analysis (RCA) provides an effective

approach.
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 What is Root Cause Analysis (RCA)

Content from National Patient Safety Agency material

http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 Def: Root Cause Analysis...
Root Cause Analysis is an evidenced based, structured
investigation process which utilises tools and
techniques to identify the true causes of an incident or
problem, by understanding what, why and how a
system failed.

Analysis of these system failures and true causes

enables targeted and, where possible, failsafe actions
to be developed and implemented which demonstrate
significantly reduced likelihood of recurrence
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Taylor-Adams (2011)
 Basic elements of RCA investigation

WHAT HOW it WHY it

happened happened happened

Unsafe Acts Human Contributory

Behaviour Factors

Solution Development & Review of effectiveness (recurrence of PSI)

‘WHO did it’

is not the objective
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 The RCA Process
Getting Started

Gathering Information & Mapping the Incident

Identifying Care & Service Delivery Problems

Analysing Problems & Identifying CFs and RCs

Generating Solutions & Recommendations

Implementing Solutions

Writing the Report

Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 Why RCA?

In depth analysis of a small number of incidents will

bring greater dividends than a cursory examination of
a large number.

Vincent and Adams - 1999

Content from National Patient Safety Agency material

http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 Why RCA?

To err is Human
To cover up is unforgivable
To fail to learn is inexcusable
Sir Liam Donaldson

Hope is not a strategy...

Aiden Halligan

Content from National Patient Safety Agency material

http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
 Key Points – What is RCA?

• RCA Investigations provide a systematic means of

reviewing and learning from incidents

• The scale of the patient safety problem is still not clear...

• ...But it is significant, and to fail to learn in inexcusable

Content from National Patient Safety Agency material

http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/