1. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Gathering and Mapping the Information

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/ Fact-finding AnalysisConclusions 60% of the time should be spent on gathering data Only once all facts have been gathered Develop targeted failsafe solutions/ recommendations AnalysisConclusionsAnalysisConclusions Investigation Management

4. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ What information to collect? Paradigms People Documentation Equipment Site

5. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Documentation 1.Incident report 2.Medical records 3.Local & national guidelines, policy, procedure (in operation at time of incident) 4.Local and national data on previous related incidents 5.Relevant integrated care pathways 6.Relevant audit data (clinical, risk management, H&S) 7.List of key staff involved and their informal statements/reports 8.Staff rotas 9.Training and supervision records 10.Medical equipment maintenance records etc

6. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ People Personnel directly involved in the incident & other witnesses Clinical staff Patient/family Porters Healthcare assistants Ward clerks Members of the public etc

7. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ How to retrieve information from people 1.Review entries made in clinical records 2.Conduct interviews (Cognitive interview recommended) 3.Request informal statements “Brain writing/brain dumping” often provides more valuable learning than formal, guided, signed witness statements. (Still request facts and observation - not opinion)

8. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Cognitive interviewing technique Developed by psychologists to enable police and social workers to help witnesses recall as much as possible, by working with what is known about how memories are stored and retrieved. R Milne & R Bull (1999), Investigative Interviewing – Psychology and Practice. Wiley, Chichester

9. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Purpose of the interview To obtain useful and accurate information about incident To help interviewee to retrieve own memory of events To check unconfirmed data

10. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Common problem with guided interview techniques & guided witness statements Interviewer in control and shaping the structure of the interview Interviewees memory sequence may not be in the same order as the interviewer asks questions Use of quick fire questions Interrupting interviewees Use of judgemental comments ( + ve or – ve)

11. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Memory is not a video recorder…. Memory is constructive – we rebuild events in our mind. We do not store exact copies. Factors will affect what memories we STORE Factors will affect which memories we RETRIEVE

12. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ The Cognitive Interview sequence Phase 1Open the Interview Establish rapport (in comfortable environment) Phase 2 Explain aims of Interview To focus on memory retrieval; transfer control; Allow retrieval at own pace and in own order Phase 3 Initiate a free Report Take their mind back to ; Report everything Good listening; accept pauses; don’t interrupt Phase 4Interviewing Ask only open questions. (No closed questioning until after step 5) Phase 5Varied, Extensive Retrieval Change order/perspective. Focus on senses. Phase 6Summary Phase 7Closure Return to safe topic and thank interviewee ‘Investigative Interview Guidance’ www.npsa.nhs.uk/rcawww.npsa.nhs.uk/rca

13. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ When Interviewing - consider Who will interview? (skills, training, reputation, objectivity) Trust’s procedures (they should cover investigative interviewing) Importance of keeping RCA separate from any disciplinary or criminal or coroner’s investigation Emotions may be triggered & support needed

14. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Recording information Consider advantages & disadvantages for each method Interviewer taking first hand report Third person in room taking first hand report Tape recorder

15. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Signed statements...... Are no longer a requirement for RCA investigations The primary aim of RCA investigations = learning Therefore, ‘first hand reports’ are taken or informal statements are requested instead This only needs to change if the aim / terms of reference change e.g. if an investigation becomes a formal HR or Criminal case.

16. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Equipment Identify and retain any equipment involved CTG machine Shower curtain Anaesthetic machine Infusion pump Drug delivery system etc

17. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Site Consider the following: Securing the site Take some photographs Sketch the layout What was the position of the equipment / people? Reconstruction

18. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Paradigms “The way we do things around here”

19. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Reference System for Gathered Data A reference or tracking system will assist data gathering and allow for successful report generation Information Requested Date RequestedDate ReceivedLocation Incident Form24/10/0125/10/01File c Medical Notes24/10/01 Nursing Notes24/10/0126/10/01File c X-Ray (s)24/10/01 Statements24/10/0129/10/01File c

20. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Key points - Data Gathering 1.Be clear about what evidence is required when planning interviews 2.You don’t need to interview everyone. Consider using a mix of informal statements, and first hand reports taken from cognitive interviews and group meetings 3.Consider ‘re-testing’ evidence by exploring apparent contradictions for clarification.

21. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Mapping the information Tabular timeline RCA Tools

22. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Progressed from the old - Narrative Chronology 14 September 2000 Four weeks later the suction was found to be permanently on, on the dental chair and the Supplier was informed. It seemed that the motor was burnt out. 21 September 2000 Seven days later the supplier came to repair the motor. The chair seemed to be working better again and disruption was minimal over the following three weeks. Community Dentistry – failure of the chair

23. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Through the – Standard Timeline 08.24 Ambulance crew partly fill diesel vehicle with unleaded petrol at local garage 08.38 Ambulance breaks down whilst on 999 call 08.32 Emergency call received by ambulance crew to attend a serious RTA on local motorway

24. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ To the tool adapted for the NHS - Tabular timeline www.npsa.nhs.uk/rca Time & Date of Event 18 March 2002 - 19.1518 March 2002 – 20.00 Event Patient seen on the ward by Consultant Anaesthetist Patient seen by SHO who applied the operation site mark Supplementary Information Patient declined regional anaesthetic. Anaesthetic pre- assess info is recorded in log- book and info transferred to the anaesthetic record on day of procedure, but this transfer did not take place on day of incident. This practice was adopted as medical & Anaesthetic records were frequently lost. SHO in first SHO job and first rotation in orthopaedics. SHO applied site mark to an unusual part of the skin (rather than thigh or knee). Below knee anti-embolic stockings put on by the patient covered the site mark. No formal guidance or training is given to SHOs on marking op sites Notable Practice Patient seen by consultant

25. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Group work Map the events Identify any data gaps Capture good practice Avoid moving into analysis

26. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Detection Factors – Decision aid How & when was the incident identified? During proactive risk assessment, prior to opening, a new or changed service At pre-admission patient assessment During care/treatment e.g.□ Via clinical assessment/observations - staff identifying a change in patient's condition □ Via Management walkaround □ By patient buzzer / call bell □ By a review □ By Incident trend □ By nationally shared learning □ From research / evidence □ By complaint or claim www.npsa.nhs.uk/rca

27. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Key Points – Gathering & Mapping Plan with care how you can best collect information from people and who you need to interview (time management) Avoid at all costs the temptation to move into analysis Always conduct a site visit