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

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

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

4. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Never Events 17 new additions from Feb. 2011 1.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 www.dh.gov.ukwww.dh.gov.uk and www.npsa.nhs.ukwww.npsa.nhs.uk

5. 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

6. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Getting Started 1.Classify the Incident 2.Establish the core investigation team 3.Scope the incident

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

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

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

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

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

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

13. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ 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) www.npsa.nhs.uk/rca Levels of RCA Investigation

14. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ www.npsa.nhs.uk/rca

15. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Examples of Concise Investigation Reports www.npsa.nhs.uk/rca

16. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ An option for concise investigations... Consider Multi-incident Investigations - With narrow themes www.npsa.nhs.uk/rca

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

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

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