Root cause analysis
Root cause analysis (RCA) is a structured approach to investigating incidents. Using this approach helps people gain a deeper understanding of the causes of an incident to ensure that the appropriate actions are taken to prevent a similar incident from happening again. RCA usually involves a team approach in order to give a broad perspective on the incident. An RCA analysis team can be as simple as just a small group of pharmacy staff, but more people will need to be involved for serious incidents. There are six steps to root cause analysis:
Getting started
Gathering and mapping information
Identifying care and service delivery problems
Analysing to identify contributory factors and root causes
The collation of data describing what happened can now be analysed to understand why the incident happened. Several techniques are useful to support this. One technique is the ‘five whys’ – simply starting by asking why something happened and taking the answers and asking why that happened, usually until you have asked ‘why’ five times, therefore going back to the causes that underpin the original events. Another technique is the NPSA fishbone diagram that reminds people to look at the various factors which may have contributed to the incident:
- Patient factors
- Individual (staff) factors
- Task factors
- Communication factors
- Team factors
- Education and training factors
- Equipment and resources
- Working condition factors
- Organisational and strategic factors.
The next step is to have a look at the findings and start thinking about why these factors were allowed to contribute to what went wrong.
Generating solutions
It is important that the focus of the RCA is orientated to prevent recurrence and, at this point, there should be enough information from the analysis to start thinking about different ways to achieve this. This may involve deciding on immediate corrective actions, both in the short term and long term, and prioritising these solutions in terms of effectiveness, acceptance from the people involved, speed of implementation and cost. There is also a need to consider what measures should be implemented to monitor the new solution and identify whether it is effective. This phase may involve the prospective risk assessment techniques described in part four of this module to ensure that the proposed solutions do not give rise to new unmanaged risks.
Log, audit and learn from investigation reports
This is the final stage of the RCA for sharing the findings, the lessons learnt and the proposed changes.