1. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Generating Solutions

2. 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

3. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Developing failsafe solutions Hazard Barriers Control measures Defences Unsuspecting target

4. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Barriers, Controls, Solutions Human Action Checking the drug dosage before administering Administrative Protocols and procedures e.g. drug administration policy Supervision and training Physical Insulation on pipes – care of elderly settings X-ray controls – only reached by staff once behind radiation shield Natural time, distance, placement Isolation of MRSA patients (placement)

5. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Solutions Hierarchy of effectiveness Stronger Actions Change cultural approach Architectural / physical plant or equipment changes Standardise and usability testing of equipment or care plans Simplify the process and remove unnecessary steps Moderately Strong Actions Effective use of skill mix Eliminate look and sound-a-likes Eliminate / reduce distractions Checklist / cognitive aids Weaker Actions Double checks Warnings and labels New procedure / policy Re-Training From: Caryl Lee and Kierston Hirschler. How to make the most of actions and outcomes Degree of difficulty

6. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Strengths and weaknesses of barriers Sign? Speed bumps? Speed camera? Speed alarm? Police car? Speed limiter? 30

7. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Key principles for solution Design Simplify tasks, processes, protocols Standardise processes and equipment Minimise dependency on short-term memory and attention span Avoid fatigue Make it easier to get it right Improve reliability in delivery of quality care / good practice Use protocols wisely Retraining is not always the right solution Skill Rule Knowledge

8. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Simply telling people to be more careful does not work! Reducing the likelihood of error

9. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Reducing the likelihood of error - Skill based mistakes Avoid external interruptions and internal distraction (but recognise multi-tasking remains a reality)

10. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Reducing the likelihood of error Routine violations = Cultural Change culture or leadership style Change beliefs Enforcing behaviour can lead to a change in beliefs - but need to recognise Cognitive dissonance

11. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Reckless violations = Personality centred Consider:- Supervision Self-awareness Harnessing innovation Manage working environment Avoid solo clinical work! Reducing the likelihood of error

12. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ - Rule and knowledge based mistakes Education may be appropriate but if so it is usually required for the whole cohort not just an individual Reducing the likelihood of error

13. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Design out the problem (find a design solution)

14. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ e.g. Clarity

15. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Preventative Actions – Decision aid Physical equipment related Physical environment related Leadership related Task design related e.g.□ Redesign the task / process □ Simplification of task / process and remove unnecessary steps □ Standardisation of tasks / processes / care plans □ Remove incentives for risk taking □ Create incentives for healthy behaviours □ Audit safety performance □ Eliminate distractions..... www.npsa.nhs.uk/rca

16. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Key Points – Generating solutions Make it easier to get things right than to get things wrong Think laterally How have other industries approached similar issues?