Root cause analysis (RCA) is not always easy. And there is frequently not enough time. So where it is done, it is common for people to take short cuts. The easiest short cuts are:
- to assume this problem is the same as one you’ve seen before and that the cause is the same (I mentioned this in a previous post). Of course, you might be right. But it might be worth taking a little extra time to make sure you’ve considered all options. The DIGR® approach to RCA can really help here as it takes everyone through the facts and process in a logical way.
- to blame someone (or a department, site etc)
Blame is corrosive. As soon as that game starts being played, everyone clams up. Most people don’t want to open up in that sort of environment because they risk every word they utter being used against them. So once blame comes into the picture you can forget getting to root cause.
To help guard against blame, it’s useful to know a little about the field of Human Factors. This is an area of science focused on designing products, systems, or processes to take proper account of the interaction between them and the people who use them. It is used extensively in the airline industry and has helped them get to their current impressive safety record. The British Health and Safety Executive has a great list of different error types.
This is based on the Human Factors Analysis and Classification System (HFACS). The error types are split into:
| Error Type | Example |
| Action errors (slips) | Turning the wrong switch on or off |
| Action errors (lapses) | Forgetting to lock a door |
| Thinking errors (rule based) – where a known rule is misapplied | Ignoring an evacuation alarm because of previous false alarms |
| Thinking errors (knowledge based) – where lack of prior knowledge leads to a mistake | Using an out-of-date map to plot an unfamiliar route |
| Non-compliance (routine, situational and exceptional) | Speeding in a car (knowingly ignoring the speed limit because everyone else does) |
So how can human factors help us? Consider a hypothetical situation where you are the Clinical Trial Lead on a vaccine study. Information is emerging that a number of the injections of trial vaccine have actually been administered after the expiry date of the vials. This has happened at several sites. It might be easiest to blame the nurse administering of the pharmacist prescribing. They should have taken more care and checked the expiry date properly. What could the human errors have been?
They might have forgotten (lapse). Or they might have read the expiry date in European date format when it was written in American date format (rule-based thinking error). Or they might have been rushing and not had time (non-compliance). Of course, we know the error occurred on multiple occasions and by different people as it happened at multiple sites. This suggests a systemic issue and that reminding or retraining staff will only have a limited effect.
Maybe it would be better to make sure that expired drug can’t reach the point of being dispensed or administered so that we don’t rely on the final check by the pharmacist and nurse. We still want them to check but do not expect them to find expired vaccine.
After all, as W. Edwards Deming said “No-one goes to work to do a bad job!”
In my next post I will talk about the different sorts of actions you can take to try to minimise the chance of human error.
And as an added extra, here’s a link to an astonishing story that emphasises the importance of taking blame out of RCA.
Photo: NYPhotographic
Text: © 2017 Dorricott MPI Ltd. All rights reserved.
DIGR® is a registered trademark of Dorricott Metrics & Process Improvement Ltd.