Title: Analysing the problems Identifying Contributing Factors and Root Causes
1Analysing the problemsIdentifying Contributing
Factors and Root Causes
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3What are Contributory Factors?
- Influencing or causal factors that contributed to
the incident. - May vary in the significance of impact on the
CDP/SDP - May have a negative or a positive impact
4- What is a Root Cause?
-
- A fundamental contributory factor
- One which, if resolved, will eradicate or have
the most significantly effect on reducing
likelihood of recurrence.
5How to identify the contributory factors and root
causes
Five Whys Technique
RCA Tools
Contributory Factors Framework/ Fishbone Diagrams
Run Charts
Brainstorming/Brainwriting NGT
6Contributory Factors Taxonomy
- (or checklist or framework)
- a detailed list of contributory factors
collected from incident investigation in
healthcare settings
7NPSA Contributory Factor Taxonomy
- Patient Factors
- Individual Factors
- Task Factors
- Communication Factors
- Team and Social Factors
- Education and Training Factors
- Equipment and Resource Factors
- Working Conditions Factors
- Organisational Strategic Factors
8Patient factors
9Organisational Strategic factors
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11 Fishbone Diagram
Individual (staff) Factors
Team Factors
Task Factors
Patient Factors
No guidance on site marking
Inexperienced SHO marked site, Unaware of correct
procedure
No check of procedure within multi-disciplinary
team
Pt helpfully removed and replaced TED to show mark
Site Marking not visible
Patients admitted too late for Cons ward round
Delay in pts admission
Concern around meeting cancelled operation targets
Lack of formal local orientation training prog
for junior Drs
Ward busy
Institutional Context Factors
Organisational Management Factors
Work Environmental Factors
12 Spider Diagram
Individual (staff) Factors
Task Factors
Team Factors
No guidance on site marking
Inexperienced SHO marked site, Unaware of correct
procedure
No check of procedure within multi-disciplinary
team
Patient Factors
Pt helpfully removed and replaced TED to show mark
Site Marking not visible
Concern around meeting cancelled operation targets
Institutional Context Factors
Patients admitted too late for Cons ward round
Delay in pts admission
Lack of formal local orientation training prog
for junior Drs
Ward busy
Work Environmental Factors
Organisational Management Factors
13Five Whys
- Tool that enables investigator(s) to identify the
causes for each problem (CDP/SDP). - Best suited to simple and non-complex problems.
- Quick and easy to teach
- 3 5 7 whys?
14Part of Cause and Effect Chart
Pt informed nurse no change since recovery
Delayed Procedure for removal of haematoma
Pt had neuro surgery
Care handed over to ward staff
Care handed over to night staff
Deterioration in condition
Deteriorating neuro observations not reported or
acted upon
Agency Nurse orientation sheet not completed
5 Whys
Nurse inexperienced and unfamiliar with obs sheet
and terminology therefore did not alert anyone to
deterioration
Ward busy and acute
Only 2 of 6 staff permanent
15Nurse did not alert Senior staff of Patients
deterioration post op
WHY?
He thought that the day staff had been aware of
condition since return form theatre
WHY?
Because on obs chart N had been recorded
throughout
WHY?
Because N is the letter for normal but he
assumed it meant Numb
WHY?
Because there was no key on the neurological
observation chart
Root Cause
16Run Charts
- Purpose
- To identify trends and patterns in a process,
over a specific period of time. - How to Construct Run Charts
- Decide what the chart will measure (what data
over what period of time. - Draw graph
17- Run Chart Example Frequency of Violence and
Aggression
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20There are more than 40 other RCA tools published
or on websites
- Hierarchical Task Analysis
- Failure Modes and Effects Analysis
- Fault Tree Analysis
- CRU/ALARM Protocol
- Event Trees
- Spider Diagrams
- Scatter Diagrams
- Etc
- RCA Simplified Tools and Techniques, Anderson
Fagerhaug - RCA in Heath CareTools and Techniques, JCAHO
- Six Steps to Root Cause Analysis, Dineen (2003)
21Group Work Analysis
- In your groups
- Use at least one of the analysis tools to pick
out - the contributory factors associated with the
case. - Finally identify the ROOT CAUSES