NPSA Incident Decision Tree
RCA Tool
(the representatives
perspective)
Cat Forsyth
UK Safety Reps
Committee
Basic elements of a good
RCA investigation
WHAT
happened
HOW it
happened
WHY it
happened
Unsafe Act
(CDP/SDP)
Human
Behaviour
Contributory
Factors
Solution Development & Feedback
Identifying the problem(s)
Problems that arise in the process of care,
usually actions or omissions by staff:
Care Delivery
Problem
(CDP)
i. care deviated beyond safe limits
of practice and
ii the deviation had a direct or
indirect effect on the eventual
adverse outcome for the patient
Identifying the problem(s) cont’d
Service
Delivery
Problem
(SDP)
SDP refers to those acts or
omissions that are identified during
the analysis of the patient safety
incident, but are not associated with
direct provision of care.
They are generally associated with
decisions, procedures and systems
that are part of the whole process of
service delivery.
What is Human Error
“We all make errors irrespective of
how much training and
experience we possess or how
motivated we are to do it right.
(in Reducing error and influencing behaviour - HSG48)
Incident Contributory Factors
•Patient factors
•Individual factors
•Task factors
•Communication factors
•Team & Social factors
•Education & Training factors
•Equipment and Resource factors
•Working Condition factors
•Organisational & management factors
Types of Violation
•Routine – involve regularly performed short-cuts between
tasks, which are accepted locally, and sometimes by
management.
•e.g not checking identities of long term patients because they
are well known
Reasoned Violations- deviation from protocol where violation
is for good reason
•Reckless Violations- are deliberate deviations from protocol,
usually harm not intended
•Malicious Violations- are deliberate and include acts of
sabotage
Updating Staff / Feedback
Staff should be kept updated on the
progress of an investigation
The chair and local manager should
determine how best to provide feedback
RCA Techniques
Timeline
•chronology event of what happened
•Easy to understand data and inter-relations
•Forms the backbone of the investigation
Fishbone Analysis
Contributory factors affecting the
performance of individuals
Five Whys
–Best suited to non-complex problems
–Each use of ‘Why?’ takes you closer to a
root cause
–Not compulsory to use five – stop when
no further benefit is gained!
Change Analysis
–A comparative technique: what was the
change that may have caused adverse
event?
–Enables you to compare a process when it
is well defined and functioning effectively but then is found to not function well i.e.
when performance problems have been
identified
Barrier Analysis
–Human action barriers
•Checking drug dosage before administering
–Administrative barriers
•Protocols and procedures, supervision, training
–Physical barriers
•Insulated pipes, lead lined aprons
–Natural barriers of place and time
•Isolation of MRSA patients
The Incident Decision Tree
•Developed by National Patient Safety Agency
(NPSA), National Clinical Assessment Authority
(NCAA), NHS Confederation, Royal Colleges and
trade unions
•Based on a model developed for the aviation
industry
•Aimed to support managers considering action
following an incident and highlighting alternative to
suspension
“Here is Edward Bear,coming
downstairs now, bump, bump, bump,
on the back of his head, behind
Christopher Robin. It is, as far as
he knows, the only way of coming
downstairs, but sometimes he feels
that there really is another way, if only
he could stop bumping for a moment
and think of it”
A.A. Milne 1926
Illustration E.H.Shepard
192614
http://www.msnpsa.nhs.uk/idt2/(
jg0xno55baejor55uh1fvi25)/inde
x.aspx
GETTING THE BALANCE
RIGHT
CHANGING THE CULTURE
MISSION IMPOSSIBLE
SEE CLEARLY THE TASK
AHEAD
contact
 cat.forsyth@tgh.nhs.uk