ROOT CAUSE ANALYSIS ROOT CASE ANALYSIS A structured

ROOT CAUSE ANALYSIS

ROOT CASE ANALYSIS • A structured evaluation method that identifies the root causes for an undesired outcome and the actions adequate to prevent recurrence. • Process analysis method which can be used retrospectively to identify the factors that cause adverse events

RCA § RCA dilakukan terus hingga faktornya dapat diidentifikasi, atau seluruh data terkait telah dibahas. § Antar disiplin, ikut dari para ahli hingga pelayanan difront office § Juga orang yang sangat familiar dengan situasi tersebut § Secara terus menerus digali lebih detail, dengan pertanyaan “Why, why? ? pada setiap level mengapa hal tersebut dapat terjadi. § Proses yang mengidentifikasi perubahan yang perlu dalam membuat suatu sistem § Proses yang diusahakan tidak memihak pada siapapun

RCA The process RCA is a critical feature of any safety and quality management system because it finds answers to the questions posed by high risk, high impact events notably : • What happened, (norms) • What should have happened? (policies) • Why it occurred and what can be done to prevent it from happening again. (actions/outcomes) § How will we know that our actions improved patient safety? (measures/tracking)

ELEMENTS OF AN EFFECTIVE RCA PROGRAM 1. Komitmen ‘Top level management’ untuk kualitas dan keamanan 2. Adanya sistem untuk memastikan ketepatan waktu laporan dari insiden 3. Adanya action untuk menangani risiko 4. Evaluasi outcome dalam merencanakan action dalam mengurangi resiko

Penyebab (Faktor Kontributor) Solusi Investigas i Pembelajaran Improve (PDCA) (Data) Analisis Rekomendasi ( POA )

FIVE PRINCIPLES OF RCA 1. Focus on systems and processes, not individual performance 2. Be fair, through and efficient 3. Focus on problem solving and not an assignment of blame 4. Use recognised analytical methods 5. Use scale of effectiveness to develop actions to eliminate or minimise risk.

INVESTIGATION 1. An investigation must be carried out. 2. Investigation should be started be immediately and completed. 3. An objective is to obtain all relevant information. Include interviewing all relevant witnesses, taking statements, obtaining documentary evidence and contacting outside agencies, bodies, or individual 4. The outcome of the investigation will take the form of a written report.

INCIDENT INVESTIGATION § Identify reasons for substandard § § § performance Identify underlying failures in management systems Learn from incidents and make recommendations Implement improvement plans to help prevent or minimize recurrences, thus reducing future risk of harm.

FIVE KEY COMPONENTS OF ANY INVESTIGATION 1. COLLECT evidence about what happened 2. ASSEMBLE and consider the evidence 3. COMPARE the findings with relevant standards, procedures or guidelines to establish the facts draw conclusions about causation and make recommendations for action to minimize risks

FIVE KEY COMPONENTS OF ANY INVESTIGATION 4. DRAW UP IMPROVEMENT PLAN with prioritized actions, responsibilities, timescales & strategies for measuring the effectiveness of actions. 5. COMMUNICATE the findings & recommendations for action with relevant staff & IMPLEMENT the improvement plan & track progress including effectiveness of actions.

INVESTIGASI 1. Mengkaji ulang laporan kasus insiden § § § Mencatat ringkasan kejadian sec kronologis & identifikasi masalah Catat staf yg terlibat Tentukan siapa yg akan diinterview 2. Batasi masalah Bagian mana dalam proses pelayanan yang akan diteliti tergantung kondisi pasien, kapan dimana insiden terjadi. Mis. Insiden perdarahan post operasi - pasien meninggal 2 minggu kmdn. Investigasi difokuskan pada : - Persiapan operasi - Selama operasi - Pengawasan pasca operasi