1. NPSA Incident Decision Tree RCA Tool (the representatives perspective)
ACTIONS WIIL ALL BE IN BOLD
Cat Forsyth
UK Safety Reps Committee

2. Solution Development & Feedback
Basic elements of a good RCA investigation
WHAT
happened
HOW it
happened
WHY it
happened
Unsafe Act
(CDP/SDP)
Human
Behaviour
Contributory
Factors
Clusters may indicate need for local RCA to identify root Cause
Local risk register should include incidents,
e.g. contributory factors e.g. number of agency staff on ward / in use if detrimental to continuity of care
Equipment -obsolete, malfunction, inappropriate, failed, not serviced ETC
Are delivery problems – service delivery problems
Solution Development & Feedback

3. Identifying the problem(s)
Problems that arise in the process of care, usually actions or omissions by staff:
Care Delivery
Problem
(CDP)
care deviated beyond safe limits of practice and
ii the deviation had a direct or indirect effect on the eventual adverse outcome for the patient
Failure to follow Guidelines/Protocols
Training and Education
Working beyond competence - ? This can also be Service as an organisational resource issue

4. Identifying the problem(s) cont’d
SDP refers to those acts or omissions that are identified during the analysis of the patient safety incident, but are not associated with direct provision of care.
They are generally associated with decisions, procedures and systems that are part of the whole process of service delivery.
Service
Delivery
Problem
(SDP)

5. What is Human Error
“We all make errors irrespective of how much training and experience we possess or how motivated we are to do it right.
(in Reducing error and influencing behaviour - HSG48)
We all make mistakes. Irrespective of how much training we have had, how much experience we possess or how motivated we are, we can still make mistakes – we are human!
Mistakes can happen when we are not under pressure or not stressed so it makes sense then to say that when we’re under pressure and stressed, then there may be an increased likelihood that harm may occur.
Failures are more serious when consequences of errors are not protected. In healthcare the consequences of error are large affecting individuals and could be very damaging to the individual so it creates more of a problem. (and barriers are rare or reliant on humans)

6. We need to develop and enhance a fair blame culture, rather than the perceived big stick
In order to improve patient safety it is essential to analyse and learn from adverse incidents that occur
Clinicians will not report adverse incidents if they believe they are going to place themselves in jeopardy from their employer or regulatory body

7. Incident Contributory Factors
Patient factors
Individual factors
Task factors
Communication factors
Team & Social factors
Education & Training factors
Equipment and Resource factors
Working Condition factors
Organisational & management factors
Patient , compliance, agitation, location, acceptance, acknowledgement
Individual, supported / inducted/ directed / skills attributed / KSF acceptance of responsibility, appropriate level of authority / autonomy
Strategic Management policies / procedures not developed / followed / ratified /lack of director / acting posts / change in organisational direction / poor clarity of roles / responsibilities
Communication miscommunication / poor paperwork / lack of validation / missing documentation
Equipment ,archaic / medical devices register / training / suitable / sufficient
Team and Social where they geographically dislocated have they recently lost a key player in the team / new team / entrenched team / at risk due to reconfiguration / managed well / under supported / under resourced / assumption due to prior knowledge
Working Conditions Working time directive implications / doctors hours an impact / new / old buildings / suitable provision / not

8. Types of Violation
Routine – involve regularly performed short-cuts between tasks, which are accepted locally, and sometimes by management.
e.g not checking identities of long term patients because they are well known
Reasoned Violations- deviation from protocol where violation is for good reason
Reckless Violations- are deliberate deviations from protocol, usually harm not intended
Malicious Violations- are deliberate and include acts of sabotage
Not using your indicator when turning off a main road into a side road in a familiar area.

9. Updating Staff / Feedback
Staff should be kept updated on the progress of an investigation
The chair and local manager should determine how best to provide feedback

10. RCA Techniques Timeline chronology event of what happened
Easy to understand data and inter-relations
Forms the backbone of the investigation
The tools and techniques are designed to inform
Some work best with individuals others with groups e.g. time line personal brainstorming groups
They are designed to enable a combination approach the choice of which will be dependant on investigators choice, preference, skills and information to be gathered.
Date and time each event recorded
Were processes and actions as they should have been?
Identifies gaps where more info may be needed
Identifies areas for deeper analysis
Highlights Care and Service delivery problems
Handout Time line

11. Fishbone Analysis Contributory factors affecting the performance of individuals
Describe each section
The tool systematically enables classification of information and how they may impact.
May identify further areas to be investigated
Exercise use scenario, incident form anonyms there may be real value in use of real incidents as knowledge of services and local procedures may enable clarity of thinking
Strategic Management policies / procedures not developed / followed / ratified / lack of director / acting posts / change in organisational direction / poor clarity of roles / responsibilities
Communication miscommunication / poor paperwork / lack of validation / missing documentation
Equipment archaic / medical devices register / training / suitable / sufficient
Team and Social- where they geographically dislocated / have they recently lost a key player in the team / new team / entrenched team / at risk due to reconfiguration / managed well / under supported / under resource / assumption due to prior knowledge
Individual- supported / inducted/ directed / skills attributed / KSF/ acceptance of responsibility / appropriate level of authority / autonomy
Working Conditions - Working time directive implications / doctors hours an impact / new / old buildings / suitable provision / not

12. Five Whys Best suited to non-complex problems
Each use of ‘Why?’ takes you closer to a root cause
Not compulsory to use five – stop when no further benefit is gained!

13. Change Analysis
A comparative technique: what was the change that may have caused adverse event?
Enables you to compare a process when it is well defined and functioning effectively - but then is found to not function well i.e. when performance problems have been identified
Medication miss-administration
due to a Packaging change

14. Barrier Analysis Human action barriers Administrative barriers
Checking drug dosage before administering
Administrative barriers
Protocols and procedures, supervision, training
Physical barriers
Insulated pipes, lead lined aprons
Natural barriers of place and time
Isolation of MRSA patients
Human - lack of training, poor training, limited physical ability e.g. arthritis, Actions / inactions
Administration protocol / policies / procedures / supervision / training records centrally etc / physical signature as a log etc
Physical bow in pipes reduces ligature in view, remove the boxing and risk increase / lag pipes to reduce burn / scald risk / locked drug fridges / two fridge's one for samples one for meds / drug keys / policies / training / authorisation / 2 nurses to check controlled drugs etc
Natural - isolation e.g. infection control / observation position of night station / special obs suicide self harm etc.
Caveat, Humans by nature try to shorten a task e.g. throwing something towards a bin rather than walk over etc.Resource intensive, Vulnerable to assumption, Knowledge short cuts
If barrier fails ask does it ? influence outcome / Cause Outcome / Lead to possible outcomes
Look at meds error in the pack

15. The Incident Decision Tree
Developed by National Patient Safety Agency (NPSA), National Clinical Assessment Authority (NCAA), NHS Confederation, Royal Colleges and trade unions
Based on a model developed for the aviation industry
Aimed to support managers considering action following an incident and highlighting alternative to suspension

16. Describe a drugs error made by a member of staff who is a controlled diabetic.
Describe incident, checked bloods, taken insulin, alarm goes off attends to incident, forgets to eat, administers meds wrongly. Go through the tool, also describe an uncontrolled diabetic who is not taking responsibility for their own health.

17. Here's the flowchart

18. Read out screen 18

19.
Link to web to undertake an IDT

20. GETTING THE BALANCE RIGHT
Partnership working shouldn’t mean balancing out on a limb
Partnership working a sound battle fry
once more into the breach
It is not the officers need it doing it and the foot soldiers do it
Safer needles a key issue in substance misuse services
Occupational health and safety reps worked together, researched what was available at congress and unison conference, occupational health and safety conference, and NHS supplies, presented finding to health and safety committee, risk management committee and the JCNC
Then trialled by service with support from reps and occupational health. From there project spread. Original unit not available in quantities require day the services. Decided to use uniform device dependant on geographic area rather than trust wide to ensure all service had access to appropriate types of devices. Now able to supply same model trust wide as NHS supplies are able to supply quantity to all services not just SMS
If health care commission and NHS purchasing are able to work together to evidence safer needles, so can organisations and staff side 20

21. CHANGING THE CULTURE
Participating in meetings may be frustrating when those responsible for health and safety appear to have no insight into their roles and responsibilities
HSE rely on reps when they land to carryout inspections or investigations in the workplace to try to obtain a balance view of employee vs. employer view of situations
It often can unnerve managers the HSE Inspectors ask for reps by name as it often the managers first contact with this HSE
One of the best things I did as a new rep was to introduce self to HSE, as a result I have been involved in several learning events, inspections and investigations within the workplace
Remember as a rep you are an agent of change, culture, partnerships, environments 21

22. MISSION IMPOSSIBLE
We are not going to revive this patient, but we need to revive the partnership working
Its not mission impossible, but
It takes time
mutual respect
commitment
drive
enthusiasm
inspiration
perspiration
Often seen as buzz words but all valid
I recently was talking to the staff side chair who said that he didn’t get health and safety and he felt that it was just about bean counters.
I pointed out that he was the first to raise challenges at the JCNC about lone workers, lighting, car parking, all of which are health and safety rather than contractual employment law. 22

23. SEE CLEARLY THE TASK AHEAD
We need to maintain a clear vision of our role
It is not as a replacement for managers
The Incident Decision Tree is a key component of the National Patient Safety Agency’s (NPSA) drive to help the NHS move away from asking “Who was to blame?” to asking “Why did the individual act in this way?” when things go wrong.
The Incident Decision Tree has been created to help NHS managers and senior clinicians decide whether they need to suspend (exclude) staff involved in a serious patient safety incident and to identify appropriate management action.  The aim is to promote fair and consistent staff treatment within and between healthcare organisations.
This tool can also be used to challenge decisions made after an incident by managers. E.g. when a staff is suspended but the tree clearly identifies systems error, training need, e.t.c 23

24. contact