Root Cause Analysis

Root Cause Analysis

Root Cause

Problem Occurs/Event

Proximate Cause

Next Level Cause

• Root Cause analysis is a process for identifying the basic casual factors that underlie occurrence of problem or event such as Test got lost, things takes too long and so on).

• Root cause analysis involves asking a series of why questions that probe deeper and deeper to build casual chain leading from problem to root cause.

• Proximate causes are immediate or most apparent reasons for the occurrence. For instance human error.

• The probing must continue until a reason underlying a cause can no longer be identified. When such a cause is identified and fixing the cause could help prevent the occurrence of event; it is a root cause.

Next Level Cause

Next Level Cause

Retained Foreign Object

Counting Error

Erroneous Entry on tally board

RN misunderstood message from surgeon

Crowded OR caused noise & difficulty in hearing

Resident observing procedures make noise

RCA Needs Probing deeper

Example

Root Cause Analysis Tools

Why?Why?

Why?

Why?

Why?

5 Why’s Fishbone Diagram

• A simple tool for looking at one major cause & drilling down to arrive at one root cause.

• A RCA tool when looking at numerous major causes and drilling down to arrive at numerous root causes based on their Cause & Effect Relationships.

Ensuring an Effective RCA• Focus primarily on systems and

processes, not on individual performance.

• Progress from special causes in clinical processes to common causes in organization processes.

• Repeatedly dig deeper by asking “Why?”; then, when answered, ask “Why?” again and so on.

• Focus on causes that team can influence, control and deal with and make changes in systems and processes-either through redesign or development of new systems or processes.

• Is though and credible.

• Root causes are systemic.• Root Causes appear far from the origin of

the failure.• The origins of root causes lie in common

cause variation of organization systems.

Characteristics of Root Causes

RCA: 5 Why’s

5 Whys

Identified problem

Root Cause

Casual factor

Casual factor

Casual factor

Casual factor

Therefore

Why

1. Go Beyond the symptom of the gap and drill down to the root cause

2. Avoid the easy answers such as:

• “It’s because we do not have enough resources or staff” or

• It’s PEDS that is the problem”

3. Data: Are there are metrics on the identified root cause?

• Ask: Is there really a problem?

Stop asking 5 whys, when:

• Corrective action(s) do not change• The answers become less important• Root cause condition is isolated

5 Why - Example

Why are the X-rays delayed?

The exams are taking longer than scheduled

Why does the exam take longer than what is scheduled?

The rad tech is busy with multiple tasks

Why is the rad tech busy?

The rad tech has to answer numerous phone calls.

What do they have to answer the phone?

The phone is in the rad tech area.

Why does the phone ring in the rad tech area?

The phone is programmed for all rad calls to be fielded to the rad tech phone.

Problem Statement : Delays in performing X-rays

Solution: Program the phone to the front desk administrator so the rad tech is not receiving

unnecessary calls

Fishbone or Cause & Effect Diagram

https://www.youtube.com/watch?v=11_pvMrWnks

Fishbone Diagram• A Cause and Effect Diagram that relates the problem and the possible

causes• The cause categories follow the 5M’s and 1E• The diagram begins to show the path to the root cause

ManMaterialEquipment

Mother NatureMethodMeasurement

What’s the Problem?

Steps in Constructing Fishbone Diagram

Define the event Find Causes Find the Root

Cause

Remembering the following 4S’s and/or 6 P’s can be helpful:4S’s: Surroundings, System, Skills & Suppliers6P’s: People, Process, Policies, Procedures, Product (Service being offered) & Place

Guidance for Finding Causes for C&E Diagram

Example of Cause & Effect Diagram/Fishbone Diagram

11

Low rate of Pap smears

Environment

People Equipment

Walk-in appts. Delay scheduled appts.

Have to wait to use exam room

Physical space limited

Space

Space used by other practitionersLong

wait time

Need for Pap

EMR function to flag provider not enabled

Appointments

No reminders for pt. appts.

No process to remind pts. of appts.

Pt. understanding

Limited time to explain procedures

Lack of pt. education regarding procedure

Staff responsibility to provide education not defined

Trained staff

Staff not well trained to use equipment

Limited funds for equipment

Specialty equipment not available. eg. tilting exam table

Staff

Staff not aware of problems with Paps

Competing priorities and time commitments

Svc. not covered by malpractice insurance

Patients

Don’t want exam

Negative past experience

Procedures

Staff not well trained to use equipment

Space used by other practitioners

Short Training Session Staff not well trained

to use equipment

Practice: RCA 5 Whys

Practice Session for RCA: 5 Why’s

Incidence of increased bleeding post surgery

One of the patients had an incidence of increased bleeding post surgery.

Lab investigation revealed that herbal supplements were present in the patient’s system increased the metabolism of several other drugs used in the perioperative period, causing increased bleeding post surgery.

The surgeon interviewed the patient and learnt that the patient had continued the use of herbal supplements right up to the day of the procedure.

After learning that the use of herbal supplements right up to the day of the procedure had caused increased bleeding, the patient was furious & complained that during the preoperative telephone interview he should have received instruction to discontinue herbal supplements prior to day of surgery.

On further inquiry the surgeon found that the preoperative telephone interview is conducted by administrative clerk and the administrative clerk did not inquire about the use of herbal supplements & suggest their discontinuation .

The administrative clerk was called for investigation. The administrative clerk defended that he had inquired and suggested about all things based on “Pre-surgery telephone interview procedure and guideline” such as discontinuation of any oral pain medications day before surgery and had not committed an error.

Identify Root Cause & Suggest Potential solution based RCA

Solution

Solution for Practice Session for RCA: 5 Why’s

Incidence of increased bleeding post surgery

Herbal supplements present in the patient’s system increased the metabolism of several drugs used in the perioperative period

Patient had continued the use of herbal supplements right up to the day of the procedure

During the preoperative telephone interview, patient did not receive instruction to discontinue herbal supplements prior to day of surgery

The administrative clerk did not inquire about the use of herbal supplements & suggest their discontinuation .

Pre-surgery telephone interview procedure and guideline does not require to inquire about use of herbal supplements and suggest its

discontinuation on day before surgery

Event

Root Cause