KAREN MEAD
SPECIALIST PRACTITION ER OF TRAN SFU SION
N ORTH BRISTOL N H S TRU ST
W h at is Ro o t Cau s e An alys is ?
Root Cause Analysis (RCA) is a technique used to
identify why a problem occurred in the first place
Sw is s Ch e e s e Mo d e l
Many layers of defense usually lie between hazards and accidents but there
are flaws in each layer which if aligned can allow the accident to occur.
Website ref - http://calleam.com/WTPF/?p=4369
Th e Ro o t Cau s e An alys is Pro ce s s
Th re e bas ic typ e s o f cau s e s
H u m an Erro r
Ao ccd rn ig to rs ch e e arch at Cm abrigd e
U in e rvtis y, it d e o s n 't m ttae r in w ah t o re d r
th e ltte e rs in a w ro d are , th e o ln y ip rm o e tn t
tih n g is tah t th e fris t an d ls at ltte e r are in th e
rgh it p clae .
Th e rs e t can be a to tal m s e s an d yo u can s itll
rae d it fialry e ails y.
Tih s is bcu s e ae th e h u am n m n id d e o s n o t rae d
e rve y lte te r by is tle f, bu t th e w ro d as a w lo h e .
H u m an Erro r - Myth s
Th e Pe rfe ctio n Myth
- if we try hard enough we
will not m ake any errors
Th e Pu n is h m e n t Myth
- if we punish people when
they m ake errors they will
m ake fewer of them
Five W h ys
Pro ble m : Yo u r clie n t is re fu s in g to p ay fo r th e le afle ts yo u p rin te d fo r
them.
Why? The delivery was late, so the leaflets couldn't be used.
Why? The job took longer than we anticipated.
Why? We ran out of printer ink.
Why? The ink was all used up on a big, last-m inute order.
Why? We didn't have enough in stock, and we couldn't order it in quickly
enough.
Counter-measure: We need to find a supplier who can deliver ink at very short
notice.
Fis h bo n e D iagram
Re d u cin g th e like lih o o d o f e rro r
Sim p ly te llin g p e o p le to be m o re care fu l d o e s n o t w o rk!
Safe ty So lu tio n s / Actio n s
Re m e d ial actio n s s h o u ld
•
Draw on the experience of NHS staff + patients / public
•
Be simple and cost effective (proportionality)
•
Target root causes or lessons learned
•
Offer a long term solution to the problem
•
Be SMART (Specific, Measurable, Achievable, Reasonable + Tim ed)
•
Have a greater positive than negative im pact on other procedures, resources
and schedules (risk assess and evaluate before im plem entation)
•
Be shared
Take H o m e Me s s age s
RCAs are used to identify and correct problem s, and should
not to used to blam e individual(s)
All contributing factors should be explored
As m uch inform ation as possible is required
Suggestions for im provem ent should be given
Feedback should be provided to everyone who contributed
to the RCA and anyone who is affected by the actions
Any Quest ions?
Re fe re n ce
National Patient Safety Agency Website:
http:/ / www.nrls.npsa.nhs.uk/ resources/ collections/
root-cause-analysis/ rca-training-course-overview/
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