1. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ 2 Day Lead Investigator Programme RootCause Analysis Investigation Training Root Cause Analysis Investigation Training

2. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ After attending this event, and using the knowledge, skills and resources gained, delegates should be better able to:- Outline and discuss the theory underpinning RCA Investigation Describe and promote effective investigation process Lead and conduct credible, thorough and proportionate RCA Investigations Introduction & Overview Learning Outcomes

3. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Resources www.npsa.nhs.uk/rca Root Cause Analysis Investigation Training

4. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ How many people are treated every day in the NHS? Over 1 million

5. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Complexity of Healthcare Number of Healthcare Diagnoses listed? > 68,000 > 4,000 > 6,000 Number of Healthcare Medications available? Number of Healthcare Procedures available? January 2010

6. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Complexity of Healthcare Healthcare has grown exponentially in its complexity This has outstripped our ability to provide care safely Dr Atul Gawande - 2009

7. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Investigation of Incidents Def: Patient Safety Incident (PSI) Any unintended or unexpected incident(s) that could have or did lead to harm for one or more persons receiving NHS funded healthcare RCA framework is also applicable for the investigation of: Claims Complaints Other types of incident (Clinical, non-clinical, social care etc) NPSA - 2003

8. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Number of Patient Safety Incidents occurring in the NHS each year? ?

9. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Patient safety - A global issue Patient Safety Incidents/ Events - True scale still unknown

10. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Hospital blunders 'kill 90,000 patients‘ Rebecca Smith: Daily Telegraph - 29.11.07 “More than 90,000 patients die and almost one million are harmed each year because of hospital blunders, research suggests” ?! Researchers found that up to half of the mistakes made were preventable

11. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Local Incident Reporting System Data Cleansing National Reporting & Learning System Analysis Tools Reports & Trends National Reporting and Learning System

12. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Systems thinking Healthcare has focused extensively on getting the best kit and the best technical expertise. £billions is spent on medical discovery annually. BUT Only a handful of people are currently ‘doing the science’ - studying how best to fit it all together safely. We need to make the complex simple, start small, and gradually improve the quality of our systems. From Dr Atul Gawande - 2009

13. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Clinical Information: 08-09 66 million OPD appointments in UK (Excl. N Ireland) 10 million had important clinical information missing Patients were exposed to risk at 2 million appointments The Health Foundation - 2010 Operating Theatre equipment (?could be applied to any healthcare equipment?) In nearly 1 in 5 operations:- the equipment was faulty, missing or used incorrectly – or staff did not know where it was or how to use it.

14. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ There is a need to learn from patient safety incidents... A systems view is needed Evidence from other complex high technology settings suggests that systematic investigation of adverse incidents can expose system failures. System failures can be the cause of human errors. Root Cause Analysis (RCA) provides an effective approach.

15. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ What is Root Cause Analysis (RCA)

16. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Def: Root Cause Analysis... Root Cause Analysis is an evidenced based, structured investigation process which utilises tools and techniques to identify the true causes of an incident or problem, by understanding what, why and how a system failed. Analysis of these system failures and true causes enables targeted and, where possible, failsafe actions to be developed and implemented which demonstrate significantly reduced likelihood of recurrence Taylor-Adams (2011)

17. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Basic elements of RCA investigation WHAT happened HOW it happened WHY it happened Unsafe Acts Human Behaviour Contributory Factors Solution Development & Review of effectiveness (recurrence of PSI) ‘WHO did it’ is not the objective

18. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Gathering Information & Mapping the Incident Identifying Care & Service Delivery Problems Analysing Problems & Identifying CFs and RCs Generating Solutions & Recommendations Implementing Solutions Writing the Report Getting Started The RCA Process

19. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Why RCA? In depth analysis of a small number of incidents will bring greater dividends than a cursory examination of a large number. Vincent and Adams - 1999

20. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ To err is Human To cover up is unforgivable To fail to learn is inexcusable Sir Liam Donaldson Hope is not a strategy... Aiden Halligan Why RCA?

21. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Key Points – What is RCA? RCA Investigations provide a systematic means of reviewing and learning from incidents The scale of the patient safety problem is still not clear......But it is significant, and to fail to learn in inexcusable