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
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