Transcript Root Cause Analysis - West Virginia University

Root Cause Analysis
Konrad C. Nau, MD
Professor and Chair
WVU Dept Family Medicine-Eastern
Division
Objectives
1) Understand importance of systemsbased thinking when adverse events
occur in medicine
2) Learn three approaches to Root Cause
Analysis
3) Understand common pitfalls
encountered when approaching patient
safety issues
What is Root Cause Analysis?
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Process for identifying contributing/
causal factors that underlie variations in
performance associated with adverse
events or near-miss/close calls
Process that features interdisciplinary
involvement of those closest to and/or
most knowledgeable about the situation
Adverse and Sentinel Events
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“Unintended injury to
patients resulting from
a medical intervention,
which includes any
action by healthcare
workers, including
clerical and
maintenance staff.”
Institute of Medicine
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“An unexpected
occurrence involving
death or serious
physical or
psychological injury or
risk thereof.”
Joint Commission
Near-Miss Events
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When two planes
nearly collide, they
call it a “near miss.”
It’s a NEAR HIT.
A collision is a “near
miss.” BOOM! “Look,
they nearly missed!”
George Carlin
The Absurd Way We
Use Language
<www.georgecarlin.com>
Where Did it Come From?
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Derivative of Failure Mode Effect
Analysis (FMEA) – US Military(1949)
to determine effect of system and
equipment engineering failures
FMEA use by NASA for Apollo space
program (1960s)
US Auto Industry FMEA Standards
implemented (1993)
Why involve residents in RCA?
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Residents know what happens at the microprocess level
Residents are future leaders in healthcare
Residents are either team members or as implementer of
key action plans
Resident/Fellow Participation in Patient Safety Activities Baseline
 Analysis of National RCA database (many caveats)
 Residents as RCA team members < 30 (< 0.1%)
 All physicians ~ 15%!
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[email protected]
www.patientsafety.gov
Overview of RCA Steps
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Charter an inter-disciplinary team (4-6 people)
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Flow diagram of “what happened?”
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Those familiar and un-familiar with the process
Triggering questions to expand this view
Site visits and simulation to augment
Interviews with those involved or those with similar job
Resources (articles - NPSF, online databases)
Root cause/contributing factors developed
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Five rules of causation to guide/push the team deep
enough
Cause and Effect Diagram, etc
Five Causal Rules - Marx
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Rule 1 - Causal Statements must clearly
show the "cause and effect"
relationship.
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When describing why an event has occurred, you
should show the link between your root cause and
the bad outcome
each link should be clear to the RCA Team and
others.
Five Causal Rules - Marx
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Rule 2 - Negative descriptors (e.g.,
poorly, inadequate) are not used in
causal statement
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To force clear cause and effect descriptions (and
avoid inflammatory statements), we recommend
against the use of any negative descriptor that is
merely the placeholder for a more accurate, clear
description
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“The Resident Manual was poorly written” vs
“OnCall start and stop times are not documented in
policy”
Five Causal Rules - Marx
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Rule 3 - Each human error must
have a preceding cause.
 It is the cause of the error, not the error
itself, which leads us to productive
prevention strategies.
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“Joe ordered heparin and the patient bled out”
vs
“Joe order heparin because he was unaware of
a history of active Peptic Ulcer Disease in the
pt.”
Five Causal Rules - Marx
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Rule 4 - Each procedural deviation
must have a preceding cause.
 Procedural violations are like errors in that
they are not directly manageable. Instead,
it is the cause of the procedural violation
that we can manage.
Five Causal Rules - Marx
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Rule 5 - Failure to act is only causal
when there was a pre-existing
duty to act.
 A doctor's failure to prescribe a medication
can only be causal if he was required to
prescribe the medication in the first place.
 The duty to perform may arise from
standards and guidelines for practice; or
other duties to provide patient care.
NCPS RCA Model
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A rigorous,legally protected and confidential
approach to answering:
- What happened? (event or close call)
What happened that day?
What usually happens? (norms)
What should have happened? (policies)
Why did it happen?
- What are we going to do to prevent
it from happening again? (actions/outcomes)
- How will we know that our actions
improved patient safety? (measures/tracking)
-
Methods of RCA
Questioning to the Void
 Event & Causal Factor Analysis
 Safeguard Analysis
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Questioning to the Void
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A systematic approach of asking
questions:
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How is it that?
What do we know about . . .?
In Japan, called the Five Whys.
Questioning to the Void
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Toyota says ask why 5 times
Keep going until your answer to why is:
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I don’t know
I don’t care
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It fell because of gravity.
Why is there gravity?
(I don’t care)
Event & Causal Factor Analysis
Work order
written for
Oxygen
Maintenance
Shuts off
oxygen
Staff not
briefed
Valves not
Labeled
Staff reports
Patients are
Gasping.
Wrong
Valve Closed
Staff thinks
oxygen cut
off
The Bidirectional RCA Process
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Work backward chronologically from
event to see what happened
Work forward chronologically to clarify
and learn (Paradies)
Cause and effect are same thing
Effects
1. Injury
2. Fall
3. Wet surface
“caused Causes
by”
Fall
Wet surface
Leaky valve
4. Leaky valve
Seal failure
5. Seal failure
Not maintained
1
2
3
4
A continuum of causes
5
Gano
Safeguard Analysis
SOURCE
VICTIM
SAFEGUARDS
Steps in Safeguard Analysis
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Identify potential or actual source of an
event and identify the actual or
potential victim.
Identify safeguards currently in place
and determine effectiveness.
Develop plan to strengthen weak
safeguards.
Identify/deploy new safeguards.