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Jerome P


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  1. Content Article Comment
    Hi @Jon Holt Ive been saying that actions don't reflect the true root causes for a while. This is an elephant in the room. Im hoping the new framework will help. But the old world usually bites back, and usually twice as hard. What is the solution?
  2. Content Article Comment
    I completely agree with you @Katrina. More often than not, post RCA, there are numerous actions but little assurance that they are being completed in a timely manner. Readdressing the balance is so important. The Patient safety managers voices are so very small - we all know its not right...so why are we not kicking up a fuss?
  3. Content Article
    What is root cause analysis? Root cause analysis (RCA) is a structured method used to analyse serious adverse events. Initially developed to analyse industrial accidents, RCA is now widely deployed as an error analysis tool in healthcare. The RCA approach is the current methodology to investigate why and how serious incidents have happened in healthcare and to assure the Trust, Clinical Commissioning Group (CCG) and the patient/family that lessons have been learned and that the incident will not happen again. This methodology is soon to change next year as set out in the new Patient Safety Incident Response Framework. What happens to the report? Once written, the RCA report will be sent to the CCG, other outside bodies and the patient/family, alongside an action plan on how practices will change. What type of incident is RCA used for? Many Trusts will perform an RCA on incidents which are deemed to have greater learning for the Trust despite the degree of harm, moderate harm and above, and never events. Most Trusts use a modified RCA for ‘local’ investigations – these incidents may include pressure damage, falls and medication errors. What is the process? The current process of undertaking and processing a serious incident is laid out below. This is taken from the NHS Serious Incident Framework. Many Trusts will provide RCA training to anyone undertaking the lead role in an investigation – this could be a patient safety lead or a clinician. How long does it take to complete an RCA? This can depend on the experience of the investigator, the capacity of the department involved to collect statements, a timeline and information. If the incident has been declared to the CCG, the report will need to be completed within 60 days. A local RCA should take no longer than 4 weeks. How many RCAs are completed each year in the UK? During 2018 there were nearly 62,500 incidents that were reported as moderate harm or above. The majority of these would require an RCA. This figure does not include incidents that were not reported on to the Strategic Executive Information System (StEIS) but were investigated using the root cause analysis locally. Currently, patient safety teams up and down the country are drowning in writing RCA reports. We are caught up in a process of investigating harm that has already happened. Hours, days, months are spent having meetings mulling over the RCA. Looking at timelines, thinking of why the incident happened and whether there was any way for it to have been prevented. The cost of undertaking an RCA must be in the thousands of pounds. The team often includes the patient’s consultant, head of nursing, governance leads, patient safety managers and clinical staff. This group may meet up at several different occasions to make sure that all facts are correct and that the RCA is written well and meet a standard that the CCG will accept. Multiple drafts are written before submitting the final report. Action plans are found at the bottom of the RCA – once the root causes have been found, that is when the actions can be formulated. These actions will need to be carried out in the department/area where the incident took place or across the Trust if it was a system failure. Once written and signed off by the Trust and the CCG – the RCA is complete. What happens next? The end of the RCA should be the beginning of either a quality improvement initiative, a new policy, a change in practice or change in process. This part of the process is often poor – ‘reminding staff’, ‘education’ and ‘reflection’, assuming it must be human error and must be ‘fixed’ by telling people how to do it better. There is little training in setting appropriate actions or a centralised place to evidence that the action is now imbedded. The Care Quality Commission (CQC) can call on these actions and the evidence of these actions at any time. At present there is not a robust, standardised approach across the NHS to gather evidence that actions have been put in place post incident. One of the reasons for this is a lack of capacity and capability due to the industry we have made of writing the RCA and lack of quality improvement training or time provided to all staff throughout the NHS. Final words Have we forgotten the purpose of our role within patient safety? Figuring out what went wrong systemically is only one part of our role; however, assuring the family and patient that we have put new systems in place and that we are striving for this incident to never happen again is equally, if not more, important – so why is there not a standard process/industry for this? If we focussed more on the prevention we could get off the hamster wheel of investigating recurrent harm. It is hoped that the new serious incident framework will address this issue and allow us the time and the capability to put in measures to stop recurrent harm happening to patients and the public. What are your solutions to action plans and gathering the evidence for these plans? Have you a system that is easy to keep track of RCA reports and follow up? I would also be interested in the patient/public view of investigation reports and whether this type of approach is what they want?