Five rules of causation

Contributing factor and root cause statements must clearly address why something occurred with a focus on process and system vulnerabilities, not individuals. The following five rules of causation assist in developing contributing factor and root cause statements.

• Rule 1. Causal statements must clearly show the 'cause and effect' relationship.
  • If you eliminate or control this contributing factor/root cause, will you prevent or minimise future events?
    The statement should show the link between your root cause and the adverse outcome.
    Each link should be clear to the Root Cause Analysis Team and others.
    Incorrect — A resident was fatigued.
    Correct — The level of the resident's fatigue increased the likelihood that he/she misread the instructions, which led to incorrect tube insertion.
• Rule 2. Use specific and accurate descriptor for what occurred, rather than negative and vague words.
  • Negative descriptions should not be used. Avoid words such as poorly, inadequately, haphazardly, carelessness and complacency.
    These are bad choices because they are broad, negative judgments that do little to describe the actual conditions or behaviours that led to the mishap
    Incorrect — Poorly trained nurse.
    Correct — The level of the nurse's training increased the likelihood that he/she misunderstood the IV pump controls, which led to missing steps in the programming of the dose and rate.
• Rule 3. Identify the preceding cause(s) not the human error.
  • Many adverse events involve a set of events and errors; for every human error in your causal chain, you must have a corresponding cause.
    Much like Rule 1, the links need to be clear and obvious to the readers of the RCA.
    It is the cause of the error, not the error itself, which leads to productive prevention.
    Incorrect — The registrar did not review the discharge summary.
    Correct — The level of staffing caused the registrar to rush and take shortcuts resulting in the patient being discharged with the wrong discharge summary.
• Rule 4. Identify the preceding cause(s) of procedure violations.
  • Procedural violations are not directly manageable.
    Instead, it is the cause of the procedural violation that can be managed.
    The goal is to identify the positive and negative incentives that created the informal norm or accepted way of doing things
    Incorrect — The pharmacy technician did not follow the correct dispensing procedure.
    Correct — Due to staffing shortages, routine checking by two persons was bypassed resulting in the incorrect dispensing of medications.
• Rule 5. Failure to act is only causal when there is a pre-existing duty to act.
  • The duty to act may arise from standards and guidelines for practice or other duties to provide patient care.
    The failure to act is judged on the duty to act at the time the error occurred.
    Example — A doctor's failure to prescribe a cardiac medication after a myocardial infarction ca only be causal if he was required (as per agreed guideline for all practitioners) to prescribe the medication in the first place.

Actions are developed to prevent or minimise future adverse events or close calls. Actions come from the Root Cause Analysis Team asking:

1. How can we decrease the chance of the event or close call from occurring?
2. How can we decrease the injury if the event occurs?
3. If we're considering changing procedures or rules, ask — What happened that day? What should have happened ideally? What usually happens?
4. How can involved devices, software, work processes, or work space be redesigned using a human factors approach? How can we 'put knowledge in the world' instead of relying on memory and vigilance?

Actions should look at eliminating, controlling, or accepting conditions.

Eliminate

These are strong actions that may include to remove, fix or replace a piece of equipment or put a measure in place so as the problem will not occur (simplify a process and remove unnecessary steps).

Control

These are intermediate actions that may include putting up a warning notice, advising people at orientation, development of a checklist or cognitive aid, enhanced documentation/communication, software enhancements etc.

Accept

These are the weakest actions — acknowledge that there is an associated risk and accept it.

The successful implementation of actions will be increased if they are specific and clear (ie a 'cold' reader should be able to understand what to do next).

Outcome measures are designed to show whether or not the actions have actually prevented or minimised additional adverse events or close calls.
Outcome measures work best at demonstrating change over time if they are as specific and class="w3-text-red">quantifiable as possible.
Use numerators, denominators, thresholds, and timeframes wherever possible.

Outcome measures should target what you want to address — if you a have a 100% target for your measure, the vulnerability should be eliminated.
There is also a need to measure the effectiveness of your actions, not just completion of the action.
Set realistic thresholds — don't be unrealistic.