1. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Analysing the Problems Identifying Contributory Factors and Root Causes

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/ 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.

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

5. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Contributory factors framework Run chart Identifying - Contributory Factors Fishbone diagram RCA Tools

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

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

8. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Run charts or graphs Purpose To identify trends and patterns in a process, over a specific period of time, or To illustrate a trend that you have identified

9. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Run chart example: Frequency of violence and aggression in A&E A M J J A S O N D J F M A 10 8 6 4 2 Months

10. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Group work 1.Choose your top CDPs or SDPs. 2.Analyse them using a fishbone diagram and the Contributory Factors Classification in your packs.

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

12. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ A. What actually happened The patient’s journey Xxx xxxxxxxxXxxxx xxxx xxxxxxxxx xxxxxxxx xxxxxc Xxxxxxxx xxxxxxx xx xxxxxx xxxxx xxxxxx Xxxxx xxxx xxxxxxxxxx xxxxx xxxx xxxx xxxxxx 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 1. Care & Service Delivery Problems Variations from acceptable practice (Actions, Errors and Omissions) Xxxx xxxxxxx xxxxxxxxxxx xxxxxxxxxxxxx xxx Xxxxxxxxxxxx xxxxxxxx xxxxxxxx xx xxxxxxxxx 2. Contributory Factors Influencing factors contributing to breach (+SRK) 3. Root Cause(s) Fundamental contributory factors (Need to identify and treat the illness, not the symptoms) LESSONS LEARNED XxXxx xx xx

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

14. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Tips to identify Root Causes or Lessons Learned Look for:- 1.The final ‘why’ when using 'five why's' methodology 2.Keep asking ‘why?’ to identify the deeper underlying cause of... Contributory factors which are behind more than one of your CDPs/SDPs e.g. poor team relationships crops up two or three times behind different CDPs/SDPs Linked contributory factors e.g. poor leadership could underlie both poor team communication & high staff turnover Contributory factors clustered most heavily on one spine of a fishbone diagram...are these linked to a single underlying cause? NB:- 'Pareto effect' or '80/20' rule - 80% of undesired behaviour will be related to 20% of causes Don’t dismiss possible causes or learning because you think there is no easy solution

15. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Drilling Down to find Root Causes 1. CDPs + SDPs - Unsafe Acts & Unsafe conditions  2. Contributory Factors (Proximate causes) - Process Issues  3. Root Causes - (Causal factors) Systemic Issues  Root Causes - Leadership Issues  Root Causes - Societal Issues  Root Causes - Economy Issues Drill down to at least  this level before considering solutions Drill down to here  if at all possible

16. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ The value equation Stop at issues within the control of the organisation You may want to identify those issues beyond control of the organisation - for escalation

17. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Group work Identify possible Root Causes in relation to the case study under investigation

18. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Liability Just as: An apology ≠ Admission of Liability Identification of Root Causes & Lessons learned ≠ Liability

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