Sentinel Event Workshop

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Sentinel Event Workshop
Root Cause Analysis Education Marg Way Clinical
Governance Program Manager, Austin Health
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Why is an RCA Education Program needed in
Victoria?

• DHS provided a number of RCA training programs
  attended by Risk Management and clinical staff in
  Victoria.
• Further educational requirements have been
  identified by DHS, including the need for ongoing
  education and training supported by a Resource
  Kit and Manual.

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The RCA Manual

• The Department has sponsored the development of a
  manual with practitioners from the field.
• Authors
• Jo Bourke, Risk Manager, Barwon Health
• Pam Dolley, Quality Manager, Barwon Health
• Sue Kirsa, Clinical Outcome Review
  Coordinator, Austin Health
• Dr Andy Kattula, Clinical Outcome Review
  Clinician, Austin Health

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What was the development process of the RCA
Manual?

• CRM Reference Group sponsored
• Support from Victorian Quality Council
• Review of national, international RCA models
  including Veterans Affairs (VA), NSW modified VA
  model
• Consultation process with metro, regional and
  rural Clinical Risk Managers
• Current international benchmarking including
  National Patient Safety Agency (NPSA), United
  Kingdom, Civil Aviation Safety Authority,
  Australia and Apollo USA

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Why is an RCA investigation standard required?

• A standardised approach to undertaking RCAs and
  reporting on the results of RCAs provides patient
  safety, risk management and quality benefits.
• It assist DHS in analysis of system issues
• apples with apples comparison

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What can be achieved?

• Implementing a supported RCA Program in an
  organisation can help to shape a just and
  accountable patient safety culture.
• Identifying and acting on system failures and
  clinical risks can prevent the recurrence of
  adverse events that harm patients.

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Where does an RCA Program fit in?

• The RCA Program is part of a Clinical Safety and
  Quality Program.
• It sits alongside incident reporting, patient
  safety education and training and feeds into an
  organisations Risk Management Strategy.

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Where do RCA Investigations fit in?
Patient Safety Training
Clinical Risk Management
Incident Reporting
Patient Experience
Risk Reduction
Incident Response
Risk Assessment
Incident Investigation
Risk Identification
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What resources have been developed?

• Three resource modules are under development
• Root Cause Analysis- Whats in it for you?
• Getting started with RCA
• Conducting an RCA Investigation

Root Cause Analysis Whats in it for
you?    Module 1   An introductory guide to using
root cause analysis in Victorian healthcare
Root Cause Analysis Getting Started    Module
2     An introductory guide to establishing a
root cause analysis program in Victorian health
care organisations
Root Cause Analysis Module 3 Conducting an
Investigation
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RCA Investigation Approach
Incident Response
Step 1 Incident reported and assessed
Timeline
Responsibility
Step 2 Incident response investigation
Step 3 RCA commissioned team formed
RCA Investigation
Step 4 RCA investigation and reporting
Step 5 RCA action and risk reduction plan
Risk assessment Risk Reduction
Step 6 Apply risk management process
Step 7 Implement and evaluate change
Quality Risk Management
Step 8 Share learnings
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What does the RCA education cover?
The Context

• What is root cause analysis?
• Where does RCA fit into a clinical safety and
  quality system?
• When should an RCA be done?
• How are RCAs commissioned?
• Who is responsible for conducting an RCA?
• What training do RCA teams need?
• Who develops and monitors RCA recommendations?

When things go wrong
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What does the RCA education cover?
The RCA Structure

• An Incident response process determines the level
  of investigation and action needed.
• High impact events that have catastrophic
  outcomes require RCA.
• Commissioning and signing off RCA at Executive
  level provides the necessary authority for RCA
  Teams to investigate and identify root causes of
  preventable events.

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What does the RCA education cover?

• Conducting an Investigation
• Making staff and patients safe
• Notifications
• Forming the team
• Gathering Information
• Interviewing
• Managing documents
• Managing the RCA process
• Reporting timelines

The Techniques
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What does the RCA education cover?
The Tools

• RCA Tools
• Task analysis
• Event and Causal Factor Charting
• Understanding system and root causes
• Cause and Effect analysis
• Hazard and Barrier analysis
• Rules of Causation

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Developing RCA Recommendations

• Reporting RCA recommendations
• DHS
• Organisational
• Legal considerations
• Open disclosure
• Identifying trends and themes
• Effective actions

Reference NPSA model 2004
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What training is planned?

• A training program has been developed and will be
  piloted for RCA Team Facilitators in July.
• It is based on the Conducting an RCA
  Investigation Manual and includes RCA teaching
  aids and an RCA Team Ready to Go Pack.

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Key messages

• RCA is an important tool for organisations to use
  in identifying and acting on system failures.
• Poorly conducted RCAs may not accurately identify
  the root causes and can have adverse effects on
  an organisation
• RCAs require standardised methodology used by
  trained Facilitators with Executive commissioning
  and signoff.

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• Sentinel Event Classification

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2002-03 Analysis

• Other catastrophic event types
• Complication or emergency / resuscitation
  management 9
• Complication of surgery 9
• Foetal complication of delivery 3
• Complication of inpatient fall 2
• Patient absconding from inpatient unit with
  adverse outcome 2
• Infection control breach Hospital process issue
  9
• Other unspecified 2
• TOTAL 42

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Preliminary 2003-04 analysis

• Procedure involving wrong patient or body
  part 11
• Suicide in an inpatient unit 2
• Retained instruments or other material after
  surgery requiring
• re-operation or further surgical procedure
  7
• Intravascular gas embolism resulting in death or
  neurological
• damage 0
• Haemolytic blood transfusion reaction resulting
  from ABO
• in-compatibility 1
• Medication error leading to the death of patient
  reasonably believed
• to be due to incorrect administration of
  drugs 3
• Maternal death or serious morbidity associated
  with labour or delivery 3
• Infant discharged to wrong family 0
• Other catastrophic event 48

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Other catastrophic events

• Catastrophic medication error not leading to
  death
• Hospital system failure (power failure)
• Missed diagnosis
• Equipment malfunction

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• Now its over to you
• Option A
• Option B
• Option C