IAEA E-learning Program

IAEA E-learning Program
Safety and Quality in Radiotherapy

Safety and Quality in Radiotherapy
MODULE 6: root cause analysis 1: human factors & basic causes Sections: 6.1 Principles of Root Cause Analysis 6.2 Rasmussen’s human factors model 6.3 The New York State Incident 6.4 The Epinal Incident 6.5 The Toulouse Incident In this module, we will be discussing the principles of root cause analysis, Rasmussen’s human factors model, the New York incident, the Epinal incident and the Toulouse incident.

MODULE 6: root cause analysis 1: human factors & basic causes Sections: 6.1 Principles of Root Cause Analysis 6.2 Rasmussen’s human factors model 6.3 The New York State Incident 6.4 The Epinal Incident 6.5 The Toulouse Incident First we will look at principles of root cause analysis.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis OBJECTIVES To place Root Cause Analysis within the context of an incident learning system. To outline the key steps in a root cause analysis. To look at the membership of a group to undertake an incident investigation. To demonstrate how the incident and the events around it might be described. To discuss tracing the final event back to its basic causes. The section objectives are to place root cause analysis within the context of an incident learning system, to outline the key steps in a root cause analysis, to look at the membership of a group to undertake an incident investigation, to demonstrate how the incident and the events around it might be described, and to discuss tracing the final event back to its basic courses. We’ve talked a lot about incident learning systems, and particularly SAFRON, in previous modules. A Root Cause Analysis is the “engine” of an incident learning system and connects the incident back to what caused it and from there to corrective actions.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis OBJECTIVES To place Root Cause Analysis within the context of an incident learning system. To outline the key steps in a root cause analysis. To look at the membership of a group to undertake an incident investigation. To demonstrate how the incident and the events around it might be described. To discuss tracing the final event back to its basic causes. First, we will place root cause analysis within the context of an incident learning system.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis Where does Root Cause Analysis fit into a clinical error management and patient safety program? Root Cause Analysis (RCA) is a central feature of an incident learning system. Without a root cause analysis, there is little learning and no logical deductive basis for any corrective actions to develop. An incident learning system is a central feature of an effective safety program. Here's the question when will answer. Where does root cause analysis fit into a clinical error management and patient safety program? Root cause analysis is a central feature of an incident learning system. Without a root cause analysis, there is little learning and no logical deductive basis for any corrective actions to develop. An incident learning system is a central feature of an effective safety program.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis A generic Incident Learning System Here's a reminder of our generic incident learning system.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis Incident Learning System The name, root cause analysis, suggests that the activity concerns itself just with the investigation and concludes with the identification of basic or root causes. Here is where the root cause analysis fits in. The name, root cause analysis suggests that the activity concerns itself just with the investigation and concludes with the identification of basic or root causes.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis Incident Learning System However, to be useful the activity has to encompass preventive actions and learning. The term, root cause analysis, will be interpreted here to include these extra steps. However to be useful, the activity has to encompass preventive action and learning. The term root cause analysis will be interpreted here to include these extra steps.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis Incident Learning System In this Module 6, we will explore how an investigation can lead to the identification of basic causes and contributing factors. In this module, we will explore how an investigation can lead to the identification of basic causes and contributing factors.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis Incident Learning System In further modules, we will consider how preventive actions, including safety barriers, and learning follow from a root cause analysis. In further modules, we will consider how preventive actions, including safety barriers, follow from a root cause analysis.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis OBJECTIVES To place Root Cause Analysis within the context of an incident learning system. To outline the key steps in a root cause analysis. To look at the membership of a group to undertake an incident investigation. To demonstrate how the incident and the events around it might be described. To discuss tracing the final event back to its basic causes. We will now outline the key steps in a root cause analysis.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis Root Cause Analysis: The key steps Several national organizations have developed methodologies for performing root cause analysis. For the most part the different published approaches follow a common path although details and emphasis vary. We will adopt a simplified but generic approach in our discussion. Several national organizations have developed methodologies for performing root cause analysis. For the most part the different published approaches follow a common path although details and emphasis vary. We will adopt a simplified but generic approach in our discussion. There are links to 3 of the published approaches at the end of this section.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis Root Cause Analysis: The key steps Establishing a group which undertakes the investigation. A detailed, preferably chronological, description of the incident (system failure, error). Exploration, through review of relevant clinical documents and interviews with involved persons, of the basic or root causes of the incident. On the basis of the identified basic or root causes , develop preventive actions to be implemented. Examine the success or failure of safety barriers in the context of the incident under investigation. Implement a learning plan centred on the lessons learned from the incident. Monitor the efficacy of the preventive actions and learning plan implemented. There are 7 key steps to a root cause analysis. The first three are: establishing a group which undertakes the investigation, a detailed, preferably chronological, description of the incident, and exploration through review of relevant clinical documents and interviews with involved persons, of the basic or root causes of the incident. For the purposes of this e-learning program, we have divided the key steps into 2 groups. The first three steps, we will discuss in this module. The other key steps in a root cause analysis are: to examine the success or failure of safety barriers in the context of the incident under investigation, on the basis of the identified basic or root causes, to develop preventive actions to be implemented, to implement a learning plan centred on the lessons learned from the incident, to monitor the efficacy of the preventive actions and learning plan implemented. We will discuss these four issues in further modules.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis OBJECTIVES To place Root Cause Analysis within the context of an incident learning system. To outline the key steps in a root cause analysis. To look at the membership of a group to undertake an incident investigation. To demonstrate how the incident and the events around it might be described. To discuss tracing the final event back to its basic causes. Now we will look at the membership of a group to undertake an incident investigation.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis Root Cause Analysis: The key steps A group should be established to undertake the investigation. The group comprises: Leader – knowledge of RCA and subject area of review; Facilitator – expertise in RCA; Content experts – knowledge of subject area of review; (Administrator with budget control: Preventive Actions identified may require resources). The first key steps to a root cause analysis is to establish a group which undertakes the investigation. A group comprises a leader with knowledge of a root cause analysis and subject area of review, a facilitator who has expertise in root cause analysis, content experts with knowledge of subject area of review, and an administrator with budget control. Please note that none of the team members should have been directly involved in the event. Ideally a group such as this would be formed. However, we have to do the best with the resources available. Sometimes, one person on the run has to do it. None of the team members should have been directly involved in the event.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis OBJECTIVES To place Root Cause Analysis within the context of an incident learning system. To outline the key steps in a root cause analysis. To look at the membership of a group to undertake an incident investigation. To demonstrate how the incident and the events around it might be described. To discuss tracing the final event back to its basic causes. Now we will demonstrate how the incident and the events around it might be described.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis Root Cause Analysis: The key steps A detailed, preferably chronological, description of the events which preceded the incident. The importance of this step is to ensure that all members of the investigating team have the same and clear understanding of the events which took place. The second step in a root cause analysis is a detailed, preferably chronological description of the events which preceded the incident. The importance of this step is to ensure that all members of the investigating team have the same and clear understanding of the events which took place. A diagram such as this will help ensure everyone has the same understanding of what happened. It is a form of a process map that is not generic as other ones we talked about previously. Rather, it is very specific to the events that lead up to the incident under the investigation. It is worth spending time on this important step. Importantly, we are not identifying causes at this stage Final event Event 4 Event 3 Event 2 Event 1 TIME

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis OBJECTIVES To place Root Cause Analysis within the context of an incident learning system. To outline the key steps in a root cause analysis. To look at the membership of a group to undertake an incident investigation. To demonstrate how the incident and the events around it might be described. To discuss tracing the final event back to its basic causes. Now we will discuss tracing the final event back to its basic causes. This is the essence of the root cause analysis.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis Root Cause Analysis: The key steps An exploration of the basic or root causes of the incident, through the review of relevant clinical documents and interviews with involved people. This step “asks questions” to work back from the incident through events and conditions in the clinic to the basic or root causes. This step is sometimes known as the “5 whys”. The third key step in a root cause analysis is an exploration through review of relevant clinical documents and interviews with involved persons, of the basic or root causes of the incident. This step asks questions to work back from the incident through events and conditions in the clinic to the basic or root causes. This step is sometimes known as the ‘5 whys’. Incident Event/ condition Basic Cause Caused by? Why?

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis A Reminder from Module 4 Before proceeding, we remind ourselves that the term “basic (or root) causes” is used generically to describe those conditions which lead to or predispose a system to failure. Unfortunately, the use of the word “cause” implies inevitability. In other words, if the cause is eliminated, the particular failure that it precipitated will never occur again. We will continue to use the term “basic causes” although it should be interpreted to include contributing factors and latent conditions which increase the probability of system failure but do not make failure inevitable. Here is an important reminder from module 4. We remind ourselves that the term ‘basic causes’ is used generically to describe those conditions which lead to or predispose a system to failure. Unfortunately, the use of the word “Cause” implies inevitability. In other words, if the Cause is eliminated, the particular failure that it precipitated will never occur again. We will continue to use the term “Basic Causes” although it should be interpreted to include Contributing Factors and Latent Conditions which increase the probability of system failure but do not make failure inevitable.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis A Reminder from Module 4: Basic Causes need to be actionable For the identification of basic causes to be useful, they need to lead to effective (preventive) actions. Inadequate documentation or insufficient staff numbers are issues that can be addressed and fixed. In contrast, “human error” is, in general, not an actionable basic cause. In tracing the origins of an incident back to basic causes, human error likely have occurred somewhere along the failure pathway. However, the value of a basic or root cause analysis is identifying the circumstances or conditions which made it more likely that a human error would be made. For example, inadequate documentation or insufficient staff numbers make errors more likely. Here is another reminder from module 4. For the identification of basic causes to be useful, they need to lead to effective preventive actions. For example, inadequate documentation or insufficient staff numbers are issues that, in principle, can be addressed and fixed. In contrast, “human error” is, in general, not an actionable Basic Cause. In tracing the origins of an incident back to basic causes, human error likely have occurred somewhere along the failure pathway. However, the value of a basic or root cause analysis is identifying the circumstances or conditions which made it more likely that a human error would be made. For example, inadequate documentation or insufficient staff numbers make errors more likely.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis Basic Causes In the examples we will discuss in Sections 6.3, 4 and 5, we will use the basic causes table from SAFRON. As we’ve seen, there are several varieties of basic cause tables in use by different systems. For consistency, we will just use the SAFRON table.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis From the event to basic causes Different presentations can help tracing and understanding the links between the event and the basic causes. Different presentations can help tracing and understanding the links between the event and the basic courses. Tracing back from the incident to the basic causes maybe presented in the form of a cause and effect diagram.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis From the event to basic causes Different presentations can help tracing and understanding the links between the event and the basic causes. An alternative presentation is shown here. This one is from the London protocol. In this case, CDP means Care Delivery Problem.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis Final Question: A Root Cause Analysis seems like a lot of work particularly for minor or potential incidents? Experience shows that many of the basic causes identified in connection with one incident are issues across the whole clinical program. For example, if inadequate documentation is found to be a basic cause for one particular incident it is very likely that the clinical program as a whole has a documentation problem. The benefit of a root cause analysis extends well beyond minimizing the probability of one or a few particular incidents being repeated. Here's a question that we often think about when we realize that a root cause analysis can be a fairly complex and time-consuming activity. Experience shows that many of the Basic Causes identified in connection with one incident are issues across the whole clinical program. For example, if inadequate documentation is found to be a Basic Cause for the particular incident under investigation it is very likely that the clinical program as a whole has a documentation problem.The benefit of a root cause analysis extends well beyond minimizing the probability of one or a few particular incidents being repeated.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis summary We have: Placed root cause analysis within the context of an incident learning system. Outlined the key steps in a root cause analysis. Looked at the membership of a group to undertake an incident investigation. Demonstrated how the incident and the events around it might be described. Discussed tracing the final event back to its basic causes. In summary, we have placed root cause analysis within the context of an incident learning system, outlined the key steps in a root cause analysis, looked at the membership of a group to undertake an incident investigation, demonstrated how the incident and the events around it might be described, and discussed tracing the final event back to its basic causes. If you decide to make a root cause analysis of feature of your safety program, you might want to pick one of the evaluable methodologies and adopt it as your standard approach. Whichever one you choose will take you to essentially the same place, however, given the complexity and resources involved in doing a good root cause analysis, it is worth mastering just one approach well. The first root cause analysis will take a while to do. But as with the other techniques we covered in this e-learning program, the more you use the tool, the faster you will become.

MODULE 6: root cause analysis 1: human factors & basic causes Section 1: Principles of Root Cause Analysis References and additional resources U.S.Veterans Administration Root Cause Analysis, The London Protocol, the_london_protocol/ Canadian Root Cause Analysis ,

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