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).

2 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. 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?

3 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.

4 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. 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.

5 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?

6 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!

7 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. 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.

8 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) Obtain mobile phone for driver, so that any issues can be dealt with whilst still with patients.

9 (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.

10 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. 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.