ROOT CAUSE ANALYSISROOT CAUSE ANALYSIS

ROOT CASE ANALYSISROOT CASE ANALYSIS

• A structured evaluation methodA structured evaluation method that that identifies the root causes for an identifies the root causes for an undesired outcome and undesired outcome and the actions the actions adequate to prevent recurrence.adequate to prevent recurrence.

• Process analysis method which can be Process analysis method which can be used retrospectively to identify the factors used retrospectively to identify the factors that cause adverse eventsthat cause adverse events

RCARCA RCA dilakukan terus hingga faktornya dapat RCA dilakukan terus hingga faktornya dapat

diidentifikasi, atau seluruh data terkait telah dibahas.diidentifikasi, atau seluruh data terkait telah dibahas. Antar disiplin, ikut dari para ahli hingga pelayanan Antar disiplin, ikut dari para ahli hingga pelayanan

difront officedifront office Juga orang yang sangat familiar dengan situasi Juga orang yang sangat familiar dengan situasi

tersebuttersebut Secara terus menerus digali lebih detail, dengan Secara terus menerus digali lebih detail, dengan

pertanyaan “Why, why?? pada setiap level mengapa pertanyaan “Why, why?? pada setiap level mengapa hal tersebut dapat terjadi.hal tersebut dapat terjadi.

Proses yang mengidentifikasi perubahan yang perlu Proses yang mengidentifikasi perubahan yang perlu dalam membuat suatu sistemdalam membuat suatu sistem

Proses yang diusahakan tidak memihak pada siapapunProses yang diusahakan tidak memihak pada siapapun

RCARCAThe process RCA is a critical feature of any safety and The process RCA is a critical feature of any safety and

quality management system because it finds answers quality management system because it finds answers to the questions posed by high risk, high impact events to the questions posed by high risk, high impact events notably : notably : • What happened, What happened, (norms)(norms)• What What shouldshould have happened? (policies) have happened? (policies)• Why it occurred and what can be done to prevent it Why it occurred and what can be done to prevent it

from happening again. from happening again. (actions/outcomes) (actions/outcomes) How will we know that our actions improved How will we know that our actions improved

patient safety? (measures/tracking) patient safety? (measures/tracking)

ELEMENTS OF AN EFFECTIVE RCA PROGRAMELEMENTS OF AN EFFECTIVE RCA PROGRAM

1.1. Komitmen ‘Komitmen ‘Top level management’Top level management’ untuk untuk kualitas dan keamanankualitas dan keamanan

2.2. Adanya sistem untuk memastikan ketepatan Adanya sistem untuk memastikan ketepatan waktu laporan dari insidenwaktu laporan dari insiden

3.3. Adanya action untuk menangani risikoAdanya action untuk menangani risiko4.4. EEvaluavaluasisi outcome outcome dalam merencanakan action dalam merencanakan action

dalam mengurangi resikodalam mengurangi resiko

Analisis Rekomendasi ( POA )

PembelajaranImprove (PDCA)

(Data)

Investigasi

Penyebab(Faktor

Kontributor)

Solusi

FIVE PRINCIPLES OF RCA FIVE PRINCIPLES OF RCA 1.1. Focus on systems and processes, not Focus on systems and processes, not

individual performanceindividual performance2.2. Be fair, through and efficientBe fair, through and efficient3.3. Focus on problem solving and not an Focus on problem solving and not an

assignment of blameassignment of blame4.4. Use recognised analytical methodsUse recognised analytical methods5.5. Use scale of effectiveness to develop Use scale of effectiveness to develop

actions to eliminate or minimise risk.actions to eliminate or minimise risk.

1. An investigation must be carried out. 1. An investigation must be carried out. 2. Investigation should be started be immediately 2. Investigation should be started be immediately

and completed. and completed. 3. An objective is to obtain all relevant 3. An objective is to obtain all relevant

information. Include interviewing all relevant information. Include interviewing all relevant witnesses, taking statements, obtaining witnesses, taking statements, obtaining documentary evidence and contacting outside documentary evidence and contacting outside agencies, bodies, or individualagencies, bodies, or individual

4. The outcome of the investigation will take the 4. The outcome of the investigation will take the form of a written report. form of a written report.

INVESTIGAINVESTIGATIONTION

INCIDENT INVESTIGATIONINCIDENT INVESTIGATION Identify reasons for substandard Identify reasons for substandard

performanceperformance Identify underlying failures in Identify underlying failures in

management systemsmanagement systems Learn from incidents and make Learn from incidents and make

recommendationsrecommendations Implement improvement plans to help Implement improvement plans to help

prevent or minimize recurrences, thus prevent or minimize recurrences, thus reducing future risk of harm.reducing future risk of harm.

FIVE KEY FIVE KEY COMPONENTS OF ANY INVESTIGATIONCOMPONENTS OF ANY INVESTIGATION

1. COLLECT1. COLLECT evidence about what happened evidence about what happened2. ASSEMBLE2. ASSEMBLE and consider the evidence and consider the evidence3. COMPARE3. COMPARE the findings with relevant the findings with relevant

standards, procedures or guidelines to standards, procedures or guidelines to establish the facts draw conclusions about establish the facts draw conclusions about causation and make recommendations for causation and make recommendations for action to minimize risksaction to minimize risks

4. DRAW UP IMPROVEMENT PLAN4. DRAW UP IMPROVEMENT PLAN with prioritized with prioritized actions, responsibilities, timescales & strategies actions, responsibilities, timescales & strategies for measuring the effectiveness of actions.for measuring the effectiveness of actions.

5. COMMUNICATE5. COMMUNICATE the findings & the findings & recommendations for action with relevant staff & recommendations for action with relevant staff & IMPLEMENT IMPLEMENT the improvement plan & track the improvement plan & track progress including effectiveness of actions.progress including effectiveness of actions.

FIVE KEY FIVE KEY COMPONENTS OF ANY INVESTIGATIONCOMPONENTS OF ANY INVESTIGATION

INVESTIGASIINVESTIGASI1.1. Mengkaji ulang laporan kasus insidenMengkaji ulang laporan kasus insiden

Mencatat ringkasan kejadian sec kronologis & identifikasi Mencatat ringkasan kejadian sec kronologis & identifikasi masalahmasalah

Catat staf yg terlibatCatat staf yg terlibat Tentukan siapa yg akan diinterviewTentukan siapa yg akan diinterview

2. Batasi masalah2. Batasi masalah Bagian mana dalam proses pelayanan yang akan diteliti Bagian mana dalam proses pelayanan yang akan diteliti

tergantung kondisi pasien, kapan dan dimana insiden tergantung kondisi pasien, kapan dan dimana insiden terjadi.terjadi.

Mis. Insiden perdarahan post operasi -Mis. Insiden perdarahan post operasi - pasien meninggal 2 minggu pasien meninggal 2 minggu kmdn.kmdn.

Investigasi difokuskan pada :Investigasi difokuskan pada : - Persiapan operasi- Persiapan operasi - Selama operasi- Selama operasi - Pengawasan pasca operasi- Pengawasan pasca operasi