Continuous Improvement: Root Cause Analysis tools

1 Continuous Improvement: Root Cause Analysis tools Following on from of 2016/17 s Quality Improvement work across the whole community pharmacy network, teams were asked what they felt they needed more support with in order to direct 2017/18 s activities. A few common themes were identified, the strongest of which was that staff felt that they would appreciate a focus on really getting to the bottom of near misses and dispensing errors to learn as a team and prevent them from happening again. When something doesn t go to plan, investigating why this might have happened takes a bit of problem solving, and is also known as Root Cause Analysis (RCA). This pack includes several simple RCA tools and explanations of how to use them, so that you and your teams can try them out and find one (or more!) that you feel comfortable using. Mistakes can be upsetting for some people, but they can also be seen as a great learning opportunity for everyone, as long as the right tools and attitude are applied.

2 The Five whys This is probably the simplest RCA tool that can be used to find the underlying factors which may have lead to a mistake being made, but it is also very effective when used properly. We call this the Five whys because on average, this is how many times a team asks Why? to truly get to the bottom of a problem. Sometimes it might take more than five whys , and sometimes it will be fewer. 1. First, write down the problem you are dealing with as clearly and in as few words as possible. 2. Make sure everyone agrees that they are talking about the same problem. 3. Ask the team: Why did this happen? . Write down the answer that you all agree on. This should be as simple an answer as possible - it might take a bit of practice to get right! 4. Continue to ask Why? to the previous answer, until the problem s root Cause has been identified. 5. From the bottom up, look at all the written answers and agree what action might be taken at each step to stop the problem from happening again.

3 Make these actions clear and include timescales and responsibilities. Worked example Date: 11/01/2018 What is the problem? The wrong strength of Amitriptyline was dispensed, but did not reach the patient. Why? Wrong strength selected from shelf. Why? Some 10mg packs were in the 25mg location. Kept right next to one another. Why? They were mixed up when putting order away both strengths were in the same tote box. Why? Similar packaging, and the order was put straight on the shelf from the tote box. Why? There was no room on the bench to lay the order out. Action taken to prevent problem Ensure benches are clear of paperwork and clutter, especially at delivery times. Who: Dispensary team When: Every Day Change SOP to have stock laid out and checked off against invoice when putting an order away. Who: Superintendent When: by 28/02/2018 Separate the strengths on the shelf with a divider Who: Karen, dispensary When: by 09/02/2018 5 whys Template Date: What is the problem?

4 Why? Why? Why? Why? Why? Action taken to prevent problem Fishbone Diagram This method is really useful when there are many factors which contributed to a problem, or if it s not clear straight away what might have led to a mistake. 1. Starting at the right hand side of the page, write down the agreed problem as clearly as possible in the fish-head space. 2. Use the heading of each fish-bone to have an open discussion about the factors contributing to the problem. You might think of lots under some headings, and none for others. Feel free to add your own headings too these are just suggestions! 3. Once you have written down all the contributing factors you can think of, decide which are the most important and explore them further if you need to ( by using the 5 whys tool ). 4. Start with the most important factors and discuss as a group what actions you might take under each heading to stop the problem happening again - write them down once you have agreed.

5 5. Assign responsibilities and timescales to any actions agreed. Worked Example Date: 16/01/2018 Patient delivered old dosette box prescription not up to date following hospital stay. Processes Staff Equipment/Resources Training Patient Environment No fax roll Patient folder not updated as in hospital after son phoned Driver had no phone Dispenser who does trays off sick No-one on shift knew how to amend backing sheet once discharge letter came through Poor vision didn t notice new tablets were missing PMR computers too busy to check NHS Mail Didn t hand discharge letter in to GP HCA didn t feel he could ask dispenser for help NHS Mail not checked HCA took phone call from son, put post-it on assembled trays Has dementia Tray area messy post-it fell off Actions agreed Review process for dosette patients in hospital and carry out training session (+PMR training for dispensary staff) (Pharmacist, end March) Train at least three staff on how to use tablet to access NHS Mail twice daily so discharges aren t missed (Supervisor, end February)

6 Obtain mobile phone for driver, so that any issues can be dealt with whilst still with patients. (Manager, end of week) Re=organise dosette box storage area and ensure one basket for each patient (End of day) Fishbone Diagram Template Date: Process Staff Equipment/Resources Training Patient Environment Root Cause Analysis Report form This form is really useful to use alongside your SOPs to find out where things might have gone wrong in the lead-up to a problem. By writing down the sequence of what should have happened, it s easy to see where something was different to your expectations. 1. As with the other tools , agree upon the problem and write it down clearly. 2. Fill out the environment section with the expected and actual factors 3. Fill out the process section with the expected and actual sequence of events leading up to the problem 4. Compare the expected and actual columns for both sections above, and write down any differences you notice which might have contributed to the problem.

7 5. Discuss the differences you have noticed as a team, and decide why these might have happened. (You can use the 5 whys if you like) 6. Agree upon any actions which might stop them from happening again and include responsibilities and timelines. Worked Example Date: 23/01/2018 Root Cause Analysis form Problem CD balance of MST 10mg was incorrect when register balance check carried out. One patient s supply had not been written through a fortnight ago. Environment Expected Actual Full staffing 2 HCA s, 2 Dispensers and Pharmacist Stock of stationery full Clear till area Tidy CD cabinet Time to check all expected items with patients collecting Rxs Sick bug meant only 1 HCA, 1 Dispenser and Pharmacist Run out of CD reminder stickers Clear till area Tidy CD cabinet Too busy to run through items with patients collecting Rxs Process Expected Actual CD dispensed and checked CD stored in safe CD reminder sticker attached to Rx Patient arrives, details checked CD retrieved from cabinet Prescription handed to patient Prescription signed and returned to collected CD Rx basket for writing up later CD Rx s written out of register at end of day CD Register balanced weekly CD Dispensed and checked CD stored in safe Patient arrives, details checked Rx handed to patient.

8 Rx signed Patient returned later missing CD Rx checked again and CD supplied Rx placed in normal collected Rx basket CD not written out of register at end of day CD Register not balanced for nearly 3 weeks Differences observed Lower staffing levels no cover called in No CD reminder stickers had lost order form Rx collection SOP not followed when busy CD not written out at end of day on discussion this has happened quite a lot recently, and for a few different reasons. CD register balance not completed regularly enough harder to investigate discrepancies Actions agreed Establish a process for staff transfer between branches when necessary (Owner, end Feb) Get sister branch to fax a blank CD sticker order form, make copies and store a master for future use. Order plenty stock and agree minimum stockholding of 2 rolls. (Karen, dispenser) HCA s to re-read and sign Rx collection SOP (HCAs, end of week) Discuss writing up collected CDs and performing balance check on the item at the time of hand-out at next staff meeting (Manager, mid-month) Enough time on Saturday shifts to complete CD balance checks train Saturday staff and schedule as regular task.

9 (Pharmacist next Saturday) Root Cause Analysis form template Date: Root Cause Analysis form Problem Environment Expected Actual Process Expected Actual Differences observed Actions agreed