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NPSA Incident Decision Tree RCA Tool
(the representatives perspective)
Cat ForsythUK Safety Reps Committee
Basic elements of a good RCA investigation
WHAThappened
HOW ithappened
WHY ithappened
Unsafe Act (CDP/SDP)
Human Behaviour
Contributory Factors
Solution Development & Feedback
Care DeliveryProblem(CDP)
i. 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
Problems that arise in the process of care, usually actions or omissions by staff:
Identifying the problem(s)
Service DeliveryProblem(SDP)
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.
Identifying the problem(s) cont’d
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)
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
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 knownReasoned 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
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
RCA Techniques
Timeline•chronology event of what happened
•Easy to understand data and inter-relations
•Forms the backbone of the investigation
Fishbone AnalysisContributory factors affecting the performance of individuals
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!
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
Barrier Analysis
–Human action 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
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
“Here is Edward Bear,coming
downstairs now, bump, bump, bump,
on the back of his head, behind
Christopher Robin. It is, as far as
he knows, the only way of coming
downstairs, but sometimes he feels
that there really is another way, if only
he could stop bumping for a moment
and think of it”
A.A. Milne 1926
Illustration E.H.Shepard 192614
http://www.msnpsa.nhs.uk/idt2/(jg0xno55baejor55uh1fvi25)/index.aspx
GETTING THE BALANCE RIGHT
CHANGING THE CULTURE
MISSION IMPOSSIBLE
SEE CLEARLY THE TASK AHEAD
