Analyse an incident provided– See ‘Coroner’s Reports’.
In your analysis, identify the various causes that contributed to the clinical incident.
Use an RCA template to analyse the incident and identify root causes.
After analysing the root causes of the incident:
a. Prioritise one nursing-relevant strategy.
. For your chosen strategy, draw upon available evidence to justify solutions or possible strategies to minimise the risk of recu
ence of the incident.
Title: Identify the incident you have analysed.
Introduction
Clearly state what the clinical incident is, define what root cause analysis is, why using
it, what methods you are using (PLEASE USE Checklist Flip), and a
ief overview of what you
will address in this report.
Root cause analysis (350 words)
Complete root cause analysis process that identifies possible root causes of the incident. The process is two-fold: First, develop a flow diagram to show the key events crucial to understanding the incident using a maximum of 6 boxes; Then describe and categorise cause/s and/or contributing factors using the provided template.
Potential intervention (350 words)
Prioritise one nursing-relevant strategy that is likely to result in meaningful improvement, which could be implemented within the setting where the incident occu
ed. Justify your choice of strategy
The evidence base for intervention (500 words)
For your chosen strategy, locate the best available evidence-based resources. Use this evidence to support and discuss the effectiveness of the suggested intervention generally in health care.
Conclusion
Draw logical and insightful conclusions about the incident and strategies to prevent its recu
ence
Table 1 – Root Cause / Contributing Factors Table (a requirement when causes have been identified)
Documentation of causation statements is a legislative requirement. All causation statements must comply with the Rules of Causation. Describe the root cause and categorise the cause or contributing factor according to the triage cards and flip chart definitions.
· A minimum of 12 causes/factors (No significant root causes overlooked)
· Not in any specific orde
· Place a tick or cross only in the category column
Item No.
Description of root cause/contributory facto
Category (as described in the Checklist Flip Chart for Root Cause Analysis Teams)
Communication
Knowledge, skills and competence
Work environment/ scheduling
Patient factors
Equipment
Policies/ procedures
Safety mechanisms
1
2
3
4
5
6
7
8
9
10
11
12
Checklist
Flip Chart
for Root Cause Analysis Teams
Instructions
Definitions
Initial Checklist Questions
Communication
Knowledge/Skills/Competence
Work Environment/Scheduling
Patient Factors
Equipment
Policies/Procedures/Guidelines
Safety Mechanisms (Ba
iers)
Rules of Causation
Actions and Outcome Measures
Acknowledgment
The Safety and Quality Unit, Department of
Health, South Australia would like to acknowledge
the generosity of the following organisations for
permitting the reproduction and modification of
their materials for use in South Australia
Veterans Affairs, National Centre for Patient
Safety (NCPS), United States of America.
NCPS website: www.patientsafety.gov
NSW Department of Health, North Sydney,
New South Wales.
website: www.health.nsw.gov.au
Checklist Flip Chart for Root Cause
Analysis Teams - Version 1
page 2
Instructions
The following process is the recommended
framework for conducting a Root Cause
Analysis (RCA) investigation. Please note
however that the process may vary depending
on the complexity of the case.
Meeting 1
1. Make a simple flow diagram of the activities
that su
ounded and led to the event. Limit
the diagram to five or six boxes and include
only the key events that are crucial to
understanding what happened.
Use the initial checklist questions at the
lue tab to lead you to the appropriate sets
of questions.
2. Having considered the initial checklist
questions, and asked ‘how, what and
why’ at each point of the flow diagram,
an intermediate flow diagram can be
developed.This will assist in identifying what
you know, what you don’t know and what
you need to find out.
In
st
u
ct
io
n
s
Checklist Flip Chart for Root Cause
Analysis Teams - Version 1
page 3
3. Using the aforementioned questions,
determine the information to be collected
through speaking with people, gathering
elevant documents and looking at the
literature when applicable.
Meeting 2: Part 1
1. Once all the information has been gathered
the team can construct a final flow diagram,
a detailed chronology of what happened.
2. At each point in the flow diagram, the
team should ask ‘so what?’ or ‘what is
the relevance?’ of each box in the incident
chain.
3. The team should identify whether Safety
Mechanism (ba
iers) at each step might
stop the problem from occu
ing again.
4. A cause and effect diagram can then be
constructed.This will assist in formulating the
causal links and e
or chains leading to the
contributing factors or root causes.
Checklist Flip Chart for Root Cause
Analysis Teams - Version 1
page 4
Meeting 2: Part 2
1. First, the team must outline the real problem
to be eliminated, what happened that
directly led to the event and what the team
is trying to prevent.
2. The team should
ainstorm the most
significant issues outlined in the final flow
diagram and use these for the cause and
effect diagram.
3. Continue to ask ‘why’ or ‘caused by’ at
each box on the tree until there are no more
answers.These are the contributing factors
or root causes.
Meeting 3
Development of causation statements, actions
and recommendations and key outcome
measures – see light green tab actions and
outcomes of flip chart.
Checklist Flip Chart for Root Cause
Analysis Teams - Version 1
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Remember: Before commencing an RCA,
the team must initially ascertain if the event
is outside the RCA scope, ie it appears to be
the result of:
a criminal act
a purposefully unsafe act
an act related to substance abuse by
provider or staff o
an event involving suspected patient
abuse of any kind.
If the event is thought to be related to any
of the above, it should not be reviewed using
this method but refe
ed to management to
e handled using the existing performance
management structures in your organisation.
Checklist Flip Chart for Root Cause
Analysis Teams - Version 1
page 6
Definitions
Communication
These are questions that help assess issues
elated to communication and the flow and
availability of information.These questions
also reveal the importance of communication
in the use of equipment, the application of
policies and procedures, the identification of
unintended ba
iers to communication, and
insight into the organisation’s culture with
egard to sharing information.
For example: A patient scheduled for elective
joint replacement surgery is reviewed in the
pre-admission clinic two weeks prior to the
ooked admission. On the day of surgery,
the anaesthetist notes a significantly raised
white cell count that was not documented in
the medical record.The operation is cancelled
and rescheduled following treatment for the
infection.
D
efi
n
it
io
n
s
Checklist Flip Chart for Root Cause
Analysis Teams - Version 1
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Knowledge/Skills/Competence
These are questions that help assess issues
elated to routine job training, special training,
and continuing education, including the
timing of that training.Training issues may
concern application of approved procedures,
co
ect use of equipment or appropriate
safety mechanisms.These questions also focus
attention on the interfaces between people,
workspace and equipment.
For example: A new group of resident medical
officers (RMO’s) a
ived this week to start a
otation at your facility. A laboratory e
or
occurs when the wrong form is submitted
with a blood sample.
Work Environment/Scheduling
These are questions that weigh the influence
of stress and fatigue that may result from
change, scheduling and staffing issues, sleep
deprivation and the general suitability of the
environment or the presence of environmental
distractions such as noise.These questions also
evaluate relationships between training issues,
equipment use, management concern and
involvement.
Checklist Flip Chart for Root Cause
Analysis Teams - Version 1
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For example: A RMO, having completed a
double shift the previous day, when completing
the ward discharge summaries at a busy, noisy
workstation, prescribes the wrong medications
on one discharge summary. This is recognised
in pharmacy when the medications are being
dispensed.
Patient Factors
These questions help identify the salient clinical
events or condition of the patient at the time
of the incident (eg active bleeding, labile pulse
and blood pressure) and other patient factors
that may have affected the process of care, ie
patient very distressed or unable to understand
instructions.
For example: A patient scheduled for
semiurgent insertion of a pacemaker for
a potentially life-threatening a
hythmia,
ecomes excessively agitated upon entering
the catheter lab.
The procedure cannot be performed under a
local anaesthetic and a general anaesthetic
is administered.The patient reacts to the
anaesthetic and requires intubation and
transfer to the general intensive care unit.
Checklist Flip Chart for Root Cause
Analysis Teams - Version 1
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Equipment
These are questions to help evaluate factors
elated to use and location of equipment, fire
protection, disaster drills, codes, specifications
and regulations.These questions show that
what appears to be equipment failure may
elate to human factors issues, policy and
procedure questions and training needs.
For example: An infusion pump delivering
pain relief continuously alarms. The nurse
keeps silencing the alarm – it is not until the
patient is writhing in pain that a malfunction
in the equipment is identified.
Policies/Procedures/Guidelines
These are questions that help assess the
existence and ready accessibility of directives,
including technical information for assessing
isk, mechanisms for feedback on key
processes, effective interventions developed
after previous events, compliance with national
policies, the usefulness of and incentives
for compliance with codes, standards and
egulations.
Checklist Flip Chart for