Analysing the Problems Identifying Contributory Factors and Root Causes

The RCA Process Getting Started Gathering Information & Mapping the Incident Identifying Care & Service Delivery Problems Analysing Problems & Identifying CFs and RCs Generating Solutions & Recommendations Analyse Problems + Identify Root Causes – Identify the contributory factors which conspired to cause the care and service delivery problems. The select the key/recurrent/earliest or most fundamental contributory factors as ROOT CAUSES. Implementing Solutions Writing the Report

Analysing the problems We no longer stop once we had identified the problem... ...Now we examine each CDP and SDP separately to look for the contributory factors and - ultimately - the root causes. This involves discussion, exploration, challenge and triangulation - to identify exactly what led to the incident .

What are contributory factors? = Influencing or causal factors that contributed to the incident. May vary in their significance or impact on the CDP/SDP May have a negative or a positive impact

Identifying - Contributory Factors RCA Tools Contributory factors framework Fishbone diagram

Contributory Factors Framework Detailed list of contributory factors collected from incident investigation in Healthcare Settings Patient factors Individual staff factors Task factors Communication factors Team & social factors Education & training factors Equipment & resource factors Working conditions/environment factors Organisational & strategic factors www.npsa.nhs.uk/rca

www.npsa.nhs.uk/rca Team & Social factors

Group work Choose your top CDPs or SDPs. Analyse them using a fishbone diagram and the Contributory Factors Classification in your packs.

What is a ROOT CAUSE? = A fundamental contributory factor One which had the greatest impact on the system failure. One which, if resolved, will minimise the likelihood of recurrence both locally and across the organisation. (‘Treat the illness not the symptoms’ )

RCA & ‘Drilling Down’ - to identify Root Causes B. What should have happened Policy / Guidelines / Acceptable practice Xxx xxxxxxx xxx xxxxxx xxxxxx Xx xxxx xxxx xxxxxxxxxxx xxxxxxx xxxxxxxxxx Xxxxx xxxxxx xxxxxxxxxx x xxxxxxxxxxx Xxxxxxxx xxxx xxxxxx xxxxxxxx x xxxx A. What actually happened The patient’s journey Xxx xxxxxxxx Xxxxx xxxx xxxxxxxxx xxxxxxxx xxxxxc Xxxxxxxx xxxxxxx xx xxxxxx xxxxx xxxxxx Xxxxx xxxx xxxxxxxxxx xxxxx xxxx xxxx xxxxxx 1. Care & Service Delivery Problems Variations from acceptable practice (Actions, Errors and Omissions) Xxxx xxxxxxx xxxxxxxxxxx xxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxxx xxxxxxxx xx xxxxxxxxx 2. Contributory Factors Influencing factors contributing to breach (+SRK) xx x 3. Root Cause(s) Fundamental contributory factors (Need to identify and treat the illness, not the symptoms) Xx xx LESSONS LEARNED

What is a Lesson Learned? Sometimes investigations show no root causes (nothing in the provision of healthcare directly caused the incident) However - the investigation may still identify:- 1 Primary influencing factors Variations to acceptable practice which had a bearing on but did not cause the incident. 2 Significant unrelated safety issues Poor outcomes may arise even when care delivery is in line with good practice. In these cases, investigation may still identify unrelated issues for action or research

Group work Identify possible Root Causes in relation to the case study under investigation

Key Points – Analysing Problems Tackle the analysis one CDP or SDP at a time Add value to the investigation with in-depth investigation team discussion, challenge and exploration - to identify exactly what conspired to cause the incident Where no root causes can be found (nothing within the bounds of excepted practice could have prevented the incident) identify:- - Lessons learned or - Potential need to review current best practice or - Potential need to review triggers for investigation