Transcription
KAREN MEADSPECIALIST PRACTITION ER OF TRAN SFU SIONN 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 toidentify why a problem occurred in the first place
Sw is s Ch e e s e Mo d e lMany layers of defense usually lie between hazards and accidents but thereare 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 rAo ccd rn ig to rs ch e e arch at Cm abrigd eU in e rvtis y, it d e o s n 't m ttae r in w ah t o re d rth e ltte e rs in a w ro d are , th e o ln y ip rm o e tn ttih n g is tah t th e fris t an d ls at ltte e r are in th ergh it p clae .Th e rs e t can be a to tal m s e s an d yo u can s itllrae 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 de 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 sTh e Pe rfe ctio n Myth- if we try hard enough wewill not m ake any errorsTh e Pu n is h m e n t Myth- if we punish people whenthey m ake errors they willm ake fewer of them
Five W h ysPro 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 rthem.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 quicklyenough.Counter-measure: We need to find a supplier who can deliver ink at very shortnotice.
Fis h bo n e D iagram
Re d u cin g th e like lih o o d o f e rro rSim 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 sRe 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, resourcesand schedules (risk assess and evaluate before im plem entation) Be shared
Take H o m e Me s s age sRCAs are used to identify and correct problem s, and shouldnot to used to blam e individual(s)All contributing factors should be exploredAs m uch inform ation as possible is requiredSuggestions for im provem ent should be givenFeedback should be provided to everyone who contributedto the RCA and anyone who is affected by the actions
Any Quest ions?
Re fe re n ceNational Patient Safety Agency Website:http:/ / www.nrls.npsa.nhs.uk/ resources/ collections/root-cause-analysis/ rca-training-course-overview/
What is Root Cause Analysis ? Root Cause Analysis (RCA) is a technique used to identify why a problem occurred in the first place. Swiss Cheese Model Many layers of defense usually lie between hazards and accidentsbut there are flaws in eac
