Generating Solutions
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/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
Implementing Solutions
Writing the Report
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Developing failsafe solutions
Barriers
Control
measures
Hazard
Defences
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Unsuspecting
target
Barriers, Controls, Solutions
Human Action
• Checking the drug dosage before administering
Administrative
• Protocols and procedures e.g. drug administration policy
• Supervision and training
Natural time, distance, placement
• Isolation of MRSA patients (placement)
Physical
• Insulation on pipes – care of elderly settings
• X-ray controls – only reached by staff once behind radiation shield
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Solutions
Hierarchy of effectiveness
Degree of difficulty
Stronger Actions
Change cultural approach
Architectural / physical plant or equipment changes
Standardise and usability testing of equipment or care plans
Simplify the process and remove unnecessary steps
Moderately Strong Actions
Effective use of skill mix
Eliminate look and sound-a-likes
Eliminate / reduce distractions
Checklist / cognitive aids
Weaker Actions
Double checks
Warnings and labels
New procedure / policy
Re-Training
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Strengths and weaknesses of barriers
30
•
•
•
•
•
•
Sign?
Speed bumps?
Speed camera?
Speed alarm?
Police car?
Speed limiter?
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Safety Solutions / Actions
Remedial actions should …
•
Draw on the experience of NHS staff + patients / public
•
Be simple and cost effective (proportionality)
•
Target root causes or lessons learned
•
Offer a long term solution to the problem
•
Be SMART (Specific, Measurable, Achievable, Reasonable + Timed)
•
Have a greater positive than negative impact on other procedures, resources
and schedules (Risk assess and evaluate before implementation)
•
Be shared
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Key principles for solution Design
•
•
•
•
Simplify tasks, processes, protocols
Standardise processes and equipment
Minimise dependency on short-term memory and attention span
Avoid fatigue
Make it easier to get it right
• Improve reliability in delivery of quality care / good practice
• Use protocols wisely
• Retraining is not always the right solution
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Skill
Rule
Knowledge
Solutions - simple and intuitive?
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Intuitive?
Stove B
Stove A
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Standardisation!
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Reduce the likelihood of error
Simply telling people to be more careful does not work!
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Reduce the likelihood of error
Skill based mistakes
Avoid external interruptions and internal distraction
(but recognise multi-tasking remains a reality)
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Reduce the likelihood of error
Routine violations = Cultural
Change culture or
leadership style
Change beliefs
Enforcing behaviour can lead
to a change in beliefs but need to recognise
Cognitive dissonance
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Reduce the likelihood of error
Reckless violations
= Personality centred
Consider:•
•
•
•
•
Supervision
Self-awareness
Harnessing innovation
Manage working environment
Avoid solo clinical work!
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Reduce the likelihood of error
Rule and knowledge based mistakes
Education may be appropriate
but if so it is usually required
for the whole cohort
not just an individual
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Design out the problem
(find a design solution)
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
e.g. Clarity
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
IT solutions / system improvements
• Potential
• Risks
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Risk Assessment
– a valuable tool in effective solution generation and implementation
How Bad?
What Can Go
Wrong?
Is there a Need
for Action?
How Often?
(Hazards)
(Risk)
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Control + Monitor
(Risk Management)
The object of the exercise...
LIKELIHOOD
SEVERITY
1
2
3
4
5
1
1
2
3
4
5
2
2
4
6
8
10
3
3
6
9
12
15
4
4
8
12
16
20
5
5
10
15
20
25
Low
Risk
Moderate
Risk
High
Risk
Extreme
Risk
?Act last
Act Later
Act soon
Act Now!
1..Prioritisation
2. Appropriate action
All action(s) should be directed towards achieving
optimal reduction in Severity and/or Likelihood
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Solutions Options Appraisal / Impact Analysis
1
Root causes /
Lessons learned or
associated Hazards
2
3
4
5
No
a/a
RISK ASSESSMENT
Before Intervention
Risk
Strength of Potential /
reduction / Intervention Actual
(Strong/
Intervention
impact on
Medium/
option
other
Weak)
(Including do
systems
Costs of
Intervention
(Staff, Advice,
Capital, Running
costs etc)
Time
required to
Implement
RISK ASSESSMENT
After Intervention
Risk
Reduction
Potential /
Impact
Analysis
nothing)
Severity Likelihood
S = 1-5
L = 1-5
Risk Describe control
Rating
measure
SxL=1-25 to eliminate or
reduce risk
(Eliminate /
reduce
significantly /
reduce
minimally )
Non
Recurring Recurring
£
£
Severity Likelihoo Risk
S = 1-5 d L = 1-5 Rating
(Risk Rating
SxL=1-25 Before, minus
Risk Rating
After)
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
www.npsa.nhs.uk/rca
Preventative Actions – Decision aid
n
Physical equipment related
n
Physical environment related
n
Leadership related
n
Task design related
e.g.
□ Redesign the task / process
□ Simplification of task / process and remove unnecessary steps
□ Standardisation of tasks / processes / care plans
□ Remove incentives for risk taking
□ Create incentives for healthy behaviours
□ Audit safety performance
□ Eliminate distractions .....
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
www.npsa.nhs.uk/rca
Key Points – Generating solutions
•
Make it easier to get things right than to get things wrong
•
Think laterally
•
How have other industries approached similar issues?
Content from National Patient Safety Agency material
http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/