Authors (including presenting author) :
Kwok YT(1), Kwan WM(1)
Affiliation :
(1)Quality and Safety Division, New Territories West Cluster
Introduction :
In New Territories West Cluster (NTWC), root cause analysis (RCA) is conducted for investigations of sentinel and serious untoward events and other significant incidents. The conduction of RCA is known to be time and resource-consuming, however, no evaluation about the RCAs' effectiveness had ever been conducted in the NTWC. RCA training was also not conducted for a couple of years. The lack of self-evaluation and training might reduce the effectiveness of RCAs.
Objectives :
(1)To assess the appropriateness of root causes and strengths recommendations in NTWC RCA reports. (2)To train staff about human factors knowledge to enhance their performance in RCA. (3)To develop a "Useful Kit for RCA" for RCA meetings.
Methodology :
All NTWC RCA reports between 2013 and 2018 were reviewed. The appropriateness of root causes and strengths of recommendations were coded and analysed. The results were shared in the two training sessions organised for NTWC RCA facilitators and recorders. Also, a "Useful Kit for RCA" was developed by sharing the key points in staff interview, finding root causes and recommendations.
Result & Outcome :
Total 119 RCA reports were analysed. In the 333 root causes, about 40% of them were “human” related, e.g. lapse and non-compliance, while in the 512 recommendations, 13%, 39% and 48% of the recommendations had 'strong', 'medium' and 'weak' strengths respectively. The results showed that investigations might have ended when an active human error was identified, which the latent root causes were not discussed. There was also a high proportion of weak recommendations like training and reminders, which had low effectiveness. In the training sessions, human factors concepts including human failure types, action hierarchy and systems thinking were taught. These concepts were incorporated into the "Useful Kit for RCA" to facilitate RCA panel members to find more precise root causes and stronger recommendations. The project was accepted for poster presentation in the BMJ Forum on Quality and Safety, Taipei in September 2019.
