1. Analysing the Problems Identifying Contributory Factors and Root Causes

2. The RCA Process Getting Started
Gathering Information & Mapping the Incident
Identifying Care & Service Delivery Problems
Analysing Problems & Identifying CFs and RCs
Generating Solutions & Recommendations
Analyse Problems + Identify Root Causes – Identify the contributory factors which conspired to cause the care and service delivery problems. The select the key/recurrent/earliest or most fundamental contributory factors as ROOT CAUSES.
Implementing Solutions
Writing the Report

3. Analysing the problems
We no longer stop once we had identified the problem Now we examine each CDP and SDP separately to look for the contributory factors and - ultimately - the root causes. This involves discussion, exploration, challenge and triangulation - to identify exactly what led to the incident .

4. What are contributory factors?
= Influencing or causal factors that contributed to the incident.
May vary in their significance or impact on the CDP/SDP
May have a negative or a positive impact

5. Identifying - Contributory Factors
RCA Tools
Contributory factors framework
Fishbone diagram

6. Contributory Factors Framework
Detailed list of contributory factors collected from incident
investigation in Healthcare Settings
Patient factors
Individual staff factors
Task factors
Communication factors
Team & social factors
Education & training factors
Equipment & resource factors
Working conditions/environment factors
Organisational & strategic factors

7.
Team & Social factors

8. Group work Choose your top CDPs or SDPs.
Analyse them using a fishbone diagram and the Contributory Factors Classification in your packs.

9. What is a ROOT CAUSE? = A fundamental contributory factor
One which had the greatest impact on the system failure.
One which, if resolved, will minimise the likelihood of recurrence both locally and across the organisation.
(‘Treat the illness not the symptoms’ )

10. RCA & ‘Drilling Down’ - to identify Root Causes
B. What should have happened
Policy / Guidelines / Acceptable practice
Xxx xxxxxxx xxx xxxxxx xxxxxx
Xx xxxx xxxx xxxxxxxxxxx xxxxxxx xxxxxxxxxx
Xxxxx xxxxxx xxxxxxxxxx x xxxxxxxxxxx
Xxxxxxxx xxxx xxxxxx xxxxxxxx x xxxx
A. What actually happened
The patient’s journey
Xxx xxxxxxxx
Xxxxx xxxx xxxxxxxxx xxxxxxxx xxxxxc
Xxxxxxxx xxxxxxx xx xxxxxx xxxxx xxxxxx
Xxxxx xxxx xxxxxxxxxx xxxxx xxxx xxxx xxxxxx
1. Care & Service Delivery Problems
Variations from acceptable practice
(Actions, Errors and Omissions)
Xxxx xxxxxxx xxxxxxxxxxx xxxxxxxxxxxxxxxx
Xxxxxxxxxxxxxxxxxxxx xxxxxxxx xx xxxxxxxxx
2. Contributory Factors
Influencing factors contributing to breach (+SRK) xx x
3. Root Cause(s)
Fundamental contributory factors
(Need to identify and treat the illness, not the symptoms) Xx xx
LESSONS LEARNED

11. What is a Lesson Learned?
Sometimes investigations show no root causes
(nothing in the provision of healthcare directly caused the incident)
However - the investigation may still identify:-
1 Primary influencing factors
Variations to acceptable practice which had a bearing on but did not cause the incident.
2 Significant unrelated safety issues
Poor outcomes may arise even when care delivery is in line with good practice.
In these cases, investigation may still identify unrelated issues for action or research

12. Group work
Identify possible Root Causes in relation to the case study under investigation

13. Key Points – Analysing Problems
Tackle the analysis one CDP or SDP at a time
Add value to the investigation with in-depth investigation team discussion, challenge and exploration - to identify exactly what conspired to cause the incident
Where no root causes can be found (nothing within the bounds of excepted practice could have prevented the incident) identify:-
- Lessons learned or
- Potential need to review current best practice or
- Potential need to review triggers for investigation