Content from National Patient Safety Agency material Getting Started

Content from National Patient Safety Agency material 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

Content from National Patient Safety Agency material Putting Things Right - dealing with concerns Aims Develop an integrated structure which brings together complaints, claims and incident investigation processes under a single governance umbrella Ensure that a robust incident investigation structure is implemented consistently throughout the organisation to ensure that investigations are owned locally but that the process is overseen by the Senior Investigations Manager PUTTING THINGS RIGHT – dealing with concerns: WAG Interim Guidance: Sept 2009

Content from National Patient Safety Agency material Putting Things Right - dealing with concerns Requires that: there is a single point of entry for the receiving of concerns concerns are dealt with efficiently and openly concerns are properly investigated Welsh NHS bodies must give consideration to an offer of redress persons who notify concerns receive a timely and appropriate response persons who notify concerns are advised of the outcome of investigation appropriate action is taken in the light of the outcome of the investigation

Content from National Patient Safety Agency material 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’

Content from National Patient Safety Agency material Never Events 17 new additions from Feb 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 and

Content from National Patient Safety Agency material 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

Content from National Patient Safety Agency material Getting Started 1.Classify the Incident 2.Establish the core investigation team 3.Scope the incident

Content from National Patient Safety Agency material 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)

Content from National Patient Safety Agency material 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!

Content from National Patient Safety Agency material 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:

Content from National Patient Safety Agency material How the core team involve others Those involved in the incident (Patient, Carer, Relatives, Staff) Expert Advice (e.g. Experts in the field or process. Expert Patient) Core Team (2-3)

Content from National Patient Safety Agency material Suggested composition of investigation teams Core Team Investigation Lead Day-to-day Leader: Drives activities. Process expert. +/- Project Manager Support Investigator / Admin. Support Secretarial responsibility. +/- Project Manager Other Team Member Non executive Director. Lay representative. Patient representative. Normally invited in and out of the core team Process Owner(s) Know how ‘things really work around here’. Ideas for change. Test changes Experts / ‘Champions’ Understand the science. Help develop evidence-based protocols and changes. Help with process/ facilitation etc. Lead culture change.

Content from National Patient Safety Agency material 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

Content from National Patient Safety Agency material Selecting the RCA investigation team For all incident investigations need to have appropriate: Competence Objectivity Cultural sensitivity *Authority and credibility*

Content from National Patient Safety Agency material 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

Content from National Patient Safety Agency material Scope and Terms of Reference Scope = Start and finish points and extent of investigation ToR = Purpose, Structure, Common understanding What -Objectives, Scope/boundaries, Level, Deliverables How -Method, Arrangements Guidance, Resources Who -Commissioner/Sponsor, Lead, Team, Other orgs, Patient/Family When - Schedule, Realistic timeframes

Content from National Patient Safety Agency material 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) PUTTING THINGS RIGHT – dealing with concerns: WAG Interim Guidance: Sept 2009 Levels of RCA Investigation

Content from National Patient Safety Agency material

Content from National Patient Safety Agency material Examples of Concise Investigation Reports

Content from National Patient Safety Agency material An option for concise investigations... Consider Multi-incident Investigations - With narrow themes

Content from National Patient Safety Agency material 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

Content from National Patient Safety Agency material Legal Duties The Secretary of State has a statutory duty under section 2 of the NHS Act 2006 to secure patient safety. NHS bodies have a responsibility to ensure the safety and well being of patients and staff and to investigate when things go wrong. This responsibility is placed upon every NHS chief executive and upon the board of their organisation and is a critical component of corporate and clinical governance. NHS organisations must conform to national and local policies and procedures in discharging this responsibility. MOU

Content from National Patient Safety Agency material 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?

Content from National Patient Safety Agency material 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