Root Cause Analysis Policy and Procedure

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					Trust Policy and Procedure                                                                 Document re. No: PP(03)130

Root Cause Analysis Policy and Procedure

   For use in:                                   All clinical areas of the Trust
   For use by (staff groups):                    All Trust staff
   For use for:                                  Root Cause Analysis
   Document owner:                               Risk Manager
   Status:                                       Approved



Purpose of the document
To provide comprehensive guidance to Trust staff of all grades for the root cause analysis of all
incidents, complaints and litigation claims identified under the category red criteria, inquests, and
when an accumulation of specific types of incidents or complaints under the green or amber category
warrants more detailed investigation. The root cause analysis process is part of the incident reporting
procedure (PP(04) 105) and follows the recommendations provided by the National Patient Safety
Agency (NPSA).



                                                                 Contents
                                                                                                                        Page
         1. Introduction ................................................................................................... 2
         2. Root Cause Analysis process....................................................................... 3
                    2.1 Confirm Red Incident ...................................................................... 3
                    2.2 Set up pre-meeting ......................................................................... 3
                    2.3 Pre-meeting to be held.................................................................... 3
                    2.4 Chronology and information given.................................................. 3
                    2.5 Set up RCA meeting ....................................................................... 4
                    2.6 Root Cause Analysis Meeting ........................................................ 4
                    2.7 Between RCA Meeting and Review Meeting ................................. 4
                    2.8 Review Meeting............................................................................... 5


         Appendix A: Root Cause Analysis process chart............................................. 6
         Appendix B: Assessment criteria ...................................................................... 7
         Appendix C: Aide memoir and prima facie ....................................................... 8
         Appendix D: Chronology proforma ................................................................. 14
         Appendix E: Causal factors and action planning proforma ............................ 15




Source: Risk Manager                                           Issue date: October 2003                                        Page 1 of 17
Status: Approved                                               Valid until: October 2004                     Document reference: PP(03) 130
West Suffolk Hospitals NHS Trust                                         Root Cause Analysis Policy and Procedure




1. Introduction

The NHSE ‘Organisation with a Memory’ report and the subsequent document ‘Building a Safer NHS
for patients’ highlighted the requirement to ensure that the Trust system meets the proposed
standards and is capable of reporting to the National Patient Safety Agency. Full details of the
procedure are detailed in the Incident reporting and management policy and procedure PP(04)105.


As part of the system, incidents that meet the red category require a root cause analysis to establish
the causes of the incident and to identify actions to prevent its reoccurrence. When accumulations of
specific amber or green incidents or complaints give rise to concern, the root cause analysis process
will also be applied.


The process is applied to incidents, complaints, litigation claims received by the Trust. They will be
assessed against the grading criteria and, if they meet the category red criteria, a root cause analysis
will be undertaken, following the Trust procedure. Consideration will also be given as to whether an
root cause analysis is required for inquests.


A process flow chart for a root cause analysis is shown as Appendix A in this policy.



Definitions

Red category: incidents where the actual impact of the event is ‘catastrophic’ or ‘major’ (see
Appendix B for table of criteria for descriptors of severity), or where the likely potential impact of an
incident (including a near miss) would fall within these AND there is a high likelihood of recurrence.


Amber category: incidents where the actual impact is ‘moderate’, or where the likely potential impact
of an incident (including a near miss) is ‘catastrophic’ or ‘major’ with a low likelihood of recurrence, or
‘moderate’ with a high likelihood of recurrence.


Green category: All other incidents and near misses.




Source: Risk Manager                         Issue date: October 2003                                  Page 2 of 17
Status: Approved                             Valid until: October 2004               Document reference: PP(03) 130
West Suffolk Hospitals NHS Trust                                            Root Cause Analysis Policy and Procedure




2. Root Cause Analysis (RCA) process
2.1 Confirm RCA required
When a red incident or complaint are reported the grading is confirmed by the appropriate General
Manager or the Director following the standard criteria (see Appendix B). For claims and inquests an
assessment of the format of the RCA is considered in the pre-meeting (see below).


    Responsibility: General Manager/Director
    Time scale:        Within 2 working days of notification


2.2 Set up pre-meeting
Within three working days of receipt of notification of an RCA event the General Manager/Director
arranges a RCA pre-meeting with the Risk Manager to complete an aide memoir and a prima facie
(see Appendix C) and a review meeting to be held 6 weeks – 3 months after the RCA meeting (time
scale to be decided by General Manager/Director).


    Responsibility: General Manager/Director
    Time scale:        On confirmation of the RED incident


2.3 Pre-meeting to be held
The RCA pre-meeting is held to complete the aide memoir and the prima facie (see Appendix C).


The aide memoir must include:
    -    Identification of the panel chairperson (this will normally be the General Manager/Director)
    -    Membership of the RCA meeting
    -    Who will complete the chronology of the incident
    -    Sources of information required for the RCA
    -    Agree terms of reference of the panel


The prima facie must include:
    -    A description of the incident
    -    Description of actions taken at the time of the incident
    -    Initial assessment of causes


    Responsibility: General Manager/Director and Risk Manager
    Time scale:        Within three working days of the notification


2.4 Chronology and information gathering
The chronology is completed to provide a detailed summary of events before, during and after the
event (see Appendix D).

Source: Risk Manager                            Issue date: October 2003                                  Page 3 of 17
Status: Approved                                Valid until: October 2004               Document reference: PP(03) 130
West Suffolk Hospitals NHS Trust                                           Root Cause Analysis Policy and Procedure




    Responsibility: Person identified at the pre-meeting
    Time scale:        To commence immediately after the pre-meeting, with support in accessing
                       information provided by Governance Support.


2.5 Set up RCA meeting
The RCA meeting and a review meeting are arranged, and must include all membership identified in
the completed aide memoir.


    Responsibility: Secretary of General Manager/Director
    Time scale:        After completion of the aide memoir


2.6 Root Cause Analysis meeting
The RCA meeting will be held in a non-punitive manner in order to gain a clear undestanding of the
events and possible lessons to be learnt. As a result the following will be produced:
    -    Produce summary of the incident including causal factors identified on the incident
         investigation form (see Appendix E).
    -    Document an action plan with time scales and responsibilities


    Responsibility: General Manager/Director and Governance Coordinator/Risk Manager
    Time scale:        Within 45 days of the RED incident occurring


2.6 Between RCA meeting and the review meeting
A draft summary of the RCA meeting and agreed action plan is produced and must be approved. The
agreed action plan circulated to members of the RCA panel and reported to the appropriate Board
sub-committee. The implementation of the action plan to be monitored within the directorate and
reported to the Board sub-committees on an exception basis.


    Responsibility: General Manager/Director
    Time scale:        During the month between the RCA and the review meeting




Source: Risk Manager                           Issue date: October 2003                                  Page 4 of 17
Status: Approved                               Valid until: October 2004               Document reference: PP(03) 130
West Suffolk Hospitals NHS Trust                                             Root Cause Analysis Policy and Procedure




2.7 Review meeting
A meeting is arranged with all panel members to review the progress of all action contained in the
action plan. The progress of the action plan must be documented and barriers to the implementation
of actions must be identified and documented. Identified barriers must be reported to the CGC/ORC.


    Responsibility: General Manager/Director (to chair meeting) & Governance Coordinator
    Time scale:        6 weeks – 3 months after RCA meeting (time scales to be agreed by the General
                       Manager/ Director).


     Authors:                       Val Dutton, Risk Manager
     Approvals & endorsements:      Organisational Risk Committee – October 2003
     Issue no:                      1
     File name:                     S:\Governance strategies and policies\PP(03)130 Root Cause Analysis
                                    Policy and procedure 2003 12 Dec v2.doc
     Supercedes:                    New policy
     Additional Information:




Source: Risk Manager                             Issue date: October 2003                                  Page 5 of 17
Status: Approved                                 Valid until: October 2004               Document reference: PP(03) 130
West Suffolk Hospitals NHS Trust                                                  Root Cause Analysis Policy and Procedure



Appendix A: Root cause analysis chart


                                     Red event identified




                                                                              Managed by appropriate
                                      Grading confirmed              No
                                                                                   procedures




                                             Yes



                                    Set up pre RCA meeting
                                          To include:
                                 General Manager or Director
                           Risk Manager or Governance Coordinator
                                Clinical Manager (if appropriate)




                                   RCA meeting chaired by
                                   General Manager/Director




                          Report outcome of RCA and agreed action
                            plan, including summary of event, root
                           causes identified, action responsibility &
                                          time scales



                                                                               Summary report and
                                                                              action plan submitted to
                                                                               board sub-committee



                             Review progress with action plan and
                              manage progress within directorate




                            Barrier in implementation escalated to
                              appropriate board sub-committee




Source: Risk Manager                                  Issue date: October 2003                                    Page 6 of 17
Status: Approved                                      Valid until: October 2004                 Document reference: PP(03) 130
West Suffolk Hospitals NHS Trust                                                                   Root Cause Analysis Policy and Procedure
Appendix B: Assessment criteria
Descriptor             Actual or potential unintended or                 Numbers of persons         Actual or potential
                       unexpected Impact on patient(s)          OR       affected or potentially
                                                                                                 OR impact on organisation
                                                                         affected
Catastrophic           Death
                       Including-                                        •    Many (>50) persons   •     International
                                                                              affected, e.g.             adverse
                       •     unexpected death of a patient whilst             cervical screening         publicity/severe loss
                             under the direct care of a health care           concerns,                  of confidence in the
                             professional                                     vaccination error          organisation
                       •     death of a patient on GP or Health                                    •     Extended service
                             Centre premises                                                             closure
                       •     suicide or homicide committed by an                                   •     Litigation >£1
                             NHS patient being treated for a mental                                      million                     IF ACTUAL IMPACT
                             disorder                                                                                                MEETS ANY OF THE
                                                                                                                                     CRITERIA IN THIS
                       •     known or suspected case of health
                                                                                                                                     SECTION
                             care associated infection which may
                             result in death, e.g. hospital acquired
                             legionellosis                                                                                           PHONE GENERAL
Major                                                                                                                                MANAGER
                       •    Major permanent harm                         •    16-50 persons        •     National adverse
                       The following specific                                 affected                   publicity/major loss
                                                                                                                                     NOTIFY RISK OFFICE
                       incidents not resulting in                                                        of confidence in the
                       death should be categorised                                                       organisation                ASAP
                       as major:
                                                                                                   •     Temporary service           INVESTIGATION AND
                       •     procedures involving the wrong patient                                      closure                     CODING TO BE DONE
                             or body part
                                                                                                   •     Litigation £500k -          BY A GENERAL
                       •     haemolytic transfusion reaction                                             £1million                   MANAGER
                       •     retained instruments or other material
                             after surgery requiring re-operation
                       •     known or suspected case of health
                             care associated infection which may
                             result in major permanent harm, e.g.
                             Hepatitis C
                       •     patient receiving a radiation dose
                             much greater or less than intended
                             whilst undergoing a medical exposure
                       •     rape (but only on determination that a
                             rape has actually occurred, or the
                             organisation believes there is
                             sufficient evidence to make the
                             allegation a serious one)
                       •     infant abduction, or discharge to the
                             wrong family                                                                                            IF WORST ACTUAL
Moderate                                                                                                                             IMPACT MEETS ANY
                       •     Semi-permanent harm (up to 1 year) -        •    3-15 persons         •     Local adverse
                             Including known or suspected health              affected                   publicity/moderate          OF THE CRITERIA IN
                             care associated infection which may                                         loss of confidence          THIS SECTION
                             result in semi-permanent harm                                               in the organisation         INVESTIGATION AND
                                                                                                   •     Litigation £50k -           CODING TO BE DONE
                                                                                                         £500k                       BY AN OPERATIONAL
                                                                                                                                     SERVICE MANAGER
                                                                                                   •     Increased length of         or HEAD OF DEPT.
                                                                                                         stay >15 days
                                                                                                   •     Increased level of
                                                                                                         care >15 days
Minor
                       •     Non-permanent harm (up to 1 month)          •    1-2 persons          •     Litigation < £50k           INVESTIGATION AND
                             – Including known or suspected                   affected
                             health care associated infection which                                •     Increased length of         CODING TO BE DONE
                             may result in non-permanent harm                                            stay 1-15 days              BY THE LINE
                                                                                                                                     MANAGER FOR THE
                                                                                                   •     Increased level of
                                                                                                                                     AREA
                                                                                                         care 1-15 days
None
                       •     No obvious harm                             •    N/A                  •     Minimal impact, no
                                                                                                         service disruption

Management level for investigation according to POTENTIAL FUTURE risks
(if higher than actual impact on this occasion)

                                                        LIKELY consequence if the incident were to be repeated
Likelihood of recurrence                   None              Minor            Moderate              Major             Catastrophic
Almost certain
Likely
Possible
Unlikely
Rare


RED – General Manager and Risk Office to be notified by phone, GM to investigate and code
AMBER – Operational Service Manager or Head of Department to investigate and code
GREEN – Investigation and coding by area line manager

Source: Risk Manager                                                   Issue date: October 2003                                       Page 7 of 17
Status: Approved                                                       Valid until: October 2004                    Document reference: PP(03) 130
West Suffolk Hospitals NHS Trust                                             Root Cause Analysis Policy and Procedure



Appendix C: Aide memoir and prima facie

Root cause analysis – aide memoir
This proforma provides structured support to the preparation for a root cause analysis (RCA). It is anticipated
that it would form the front sheet of the documentation gathered as part of the investigation.

1. Summary information

 Name of person(s) affected
 CRN (if applicable)

 Date of incident
 Incident reference number
 (from incident form)

 Lead manager
 (usually General Manager or Director)

2. Sources of information

Any RCA is dependant on good quality information regarding the events of the incident. In order to support this
the following sources of information should be considered:

 Existing information                 Tick if         Newly gathered                                   Tick if
                                      required                                                         required
 • Medical records                                    •    Statements from those involved
 • Nursing notes                                      •    Notes of interviews
 • Drug charts                                        •    Equipment involved
 • Incident form(s)
 • Guidelines and protocols
 Other sources:                                       Other sources:


These sources of information will allow a documented chronology of events to be written and the individuals
who should be included in the RCA to be identified. The chronology is essential prior to the RCA and forms the
basis of discussion at this meeting, a template is provided in appendix I.

 Chronology to be completed by

3. Membership of the RCA panel

The individuals to form the panel will be identified through the chronology described above. It may also be
useful to hold a pre-meeting to review the chronology to ensure that all of the required information is available
and the correct personnel involved in the RCA. Composition of the RCA panel should reflect the professions
involved and were nursing issues are identified a representative from the Nursing Directorate invited to attend.

The General Manager or Director of the area involved will normally chair the RCA. Administrative support
should be clearly identified prior to the meeting.
Terms of Reference for panel to be agreed
 Name                                           Designation
                                                General Manager/Director (panel chairperson)
                                                Risk Manager
                                                Governance Co-ordinator




Source: Risk Manager                             Issue date: October 2003                                  Page 8 of 17
Status: Approved                                 Valid until: October 2004               Document reference: PP(03) 130
West Suffolk Hospitals NHS Trust                                             Root Cause Analysis Policy and Procedure



Statements and report covering prima facie facts for red category incidents

STRUCTURE/CONTENT OUTLINE FOR RECORDING STATEMENTS


Section 1         -       Biographical details
Name
Professional qualifications
Role within the Trust
Time worked within the Trust




Section 2         -       Facts relating to the Incident
Role in relation to patients
Involvement with the Incident
Chronological facts/observations
    •    What happened
    •    Support from case notes where appropriate
    •    Where it happened
    •    Who was involved
Date & Signature:




Do not include any of the following in the written statement
    •    Speculation of hypothesis
    •    Views on causes
    •    Opinions on quality of work provided by other staff
    •    Derogatory comments about what happened




Source: Risk Manager                             Issue date: October 2003                                  Page 9 of 17
Status: Approved                                 Valid until: October 2004               Document reference: PP(03) 130
West Suffolk Hospitals NHS Trust                                             Root Cause Analysis Policy and Procedure



Statements and report covering prima facie facts for red category incidents

PRIMA FACIE REPORT


A report of the incident or suspected incident should be produced within 72 hours, by the most appropriate Line
Manager, covering the prima facie facts of the incident. The following structure will aid production of the report:


Description of the Incident:
    •    what happened
    •    when it occurred
    •    who was involved
    •    reference to any statements taken


Description of action taken:
    •    Emergency procedures involved
    •    Immediate remedial action taken, and by whom and reasons
    •    Further precautions taken
    •    Press statements if prepared


Initial assessment of causes:
    •    Give reasons, evidence where possible
    •    Note any assumptions being made which would need to be tested


Detail follow-up investigation required:
    •    Give reasons


The reporting manager should be prepared to present and discuss this report with Senior Managers and Trust
Executives within 72 hours of the incident occurring.




Source: Risk Manager                             Issue date: October 2003                                 Page 10 of 17
Status: Approved                                 Valid until: October 2004               Document reference: PP(03) 130
West Suffolk Hospitals NHS Trust                                             Root Cause Analysis Policy and Procedure



Guidance to inquiry teams for red category incidents



CHOOSING THE ENQUIRY TEAM
Dependent on the nature of the incident, the enquiry panel could be internal, external or a mixture of both. In all
these cases, the team will function better of the guidelines set out below are followed:-


Chairperson
Should be skilled and independent of the issues being investigated. The Chairperson needs to be able to co-
ordinate impartially the various investigative activities, run meetings, lead a decision making process, report
writing and presentation to the client groups.


Team Members
They need the skill and specific knowledge to contribute to the investigation, so that their role in the enquiry
team can be clearly defined. They need also to be capable of playing a team role when it comes to analyzing,
agreeing decisions and making recommendations. They need to be able to, and be prepared to, give the
necessary time.


Involving Others
The Chairperson will need to recognize the need to co-opt and call upon other skills, either initially or as the
investigation ensues.


Training/Briefing Session
It should not be assumed that an enquiry team is instantly capable of carrying out its role. Ideally, its first
meeting should, at least in part, be a training session. As a minimum, an hour’s briefing by the Chairperson
should happen before starting the investigation itself. The briefing should cover:-
    •    Gaining understanding of the aims
    •    Agreeing the style and process of the investigation
    •    Sharing expectations of each role ad each other
    •    Agreeing key milestones and how the various investigative strands will be brought together
This could be facilitated or be based on a self teach package available through the Personnel Department.




ESTABLISHING TERMS OF REFERENCE
Terms of Reference should be produced in writing and shared with all those involved. They should also include:


Aims
These should be expressed in neutral language to encourage problem solving rather than blame allocation. The
remit should be broad enough to cover both circumstances around the incident and any other relevant factors
raised by the incident. A historical perspective should be encouraged to seek patterns or trends.




Enquiry Team

Source: Risk Manager                             Issue date: October 2003                                 Page 11 of 17
Status: Approved                                 Valid until: October 2004               Document reference: PP(03) 130
West Suffolk Hospitals NHS Trust                                                Root Cause Analysis Policy and Procedure



Chairperson              -         name and role in co-ordinating the investigation
Team Members             -         names and roles/specific contributions as appropriate


Time Commitment
It is likely that dedicated and intensive periods of time will be necessary to achieve the enquiry efficiently and
expeditiously and this should be clearly identified.


Secretarial Support
What clerical support will be available; where will it be located?


Authority
What authority is vested in the team and who is the person designated to receive the report?


Timescales
Following the initial 72 hour investigation, it should be possible to estimate the time required to carry out the
enquiry. One month would provide sufficient time for most incident enquiries, whilst providing an appropriate
sense of urgency. The key milestones should be indicated in the Terms of Reference.


Enquiry process
This part should include the investigation process to be undertaken, the meetings schedule, how findings will be
brought together, recommendations agreed, how the report will be presented and whether it should be/has to
be made public. These aspects should not be left to chance. It should also indicate the decision making
process by which any alterations to Terms of Reference, timescales etc., will be made in light of the progress.




ENQUIRY REPORT


Structure
The structure of reports should be broadly consistent. The following headings should suffice for most reports:-
         Introduction
         Terms of Reference – including membership of panel
         Enquiry Process
         Background – history of events
         Description of Incident and its Handling
         Comments on Incident Handling (Enquiry Team)
         Conclusions
         Recommendations
         Implementation Process
         Tracking


Recommendations



Source: Risk Manager                                Issue date: October 2003                                 Page 12 of 17
Status: Approved                                    Valid until: October 2004               Document reference: PP(03) 130
West Suffolk Hospitals NHS Trust                                          Root Cause Analysis Policy and Procedure



These could usefully be presented under three headings:-
         Policy and Procedure
         Resources and Assets
         Staff Performance and Capability
They should be prioritised in terms of MUST and COULD do. Wherever costs are entailed, these should be
itemised along with the benefits anticipated from accruing such costs.


Implementation Process
This should be in the form of an action chart, showing who, how and when by including key review points. The
plan should include communications activity and shoe how support for those involved in the implementation
process would be provided wherever this is likely to be personally stressful.


Tracking
Ownership for tracking agreed recommendations must be decided. A proforma for progress reports is attached.
These should be presented at key review points, and at least monthly, so that actions can be signed off and
any additional action can be identified.




Source: Risk Manager                          Issue date: October 2003                                 Page 13 of 17
Status: Approved                              Valid until: October 2004               Document reference: PP(03) 130
West Suffolk Hospitals NHS Trust                                                          Root Cause Analysis Policy and Procedure



Appendix D: Incident chronology

Date          Time             Description of events/action                                              Person involved
              (24 hr clock)




Source: Risk Manager                                          Issue date: October 2003                                 Page 14 of 17
Status: Approved                                              Valid until: October 2004               Document reference: PP(03) 130
 West Suffolk Hospitals NHS Trust                                                                    Root Cause Analysis Policy and Procedure

Appendix E: Causal factors and action planning proforma
Investigation and coding form
 Relates to                                                                      Reported by              Name

 Summary (to aid matching to original incident form)




 Do you agree with the estimate of impact made by the reporter? Y / N                               If not, please give your assessment below

           ACTUAL impact of incident
           (see coding criteria on back cover)               Catastrophic        Major            Moderate             Minor            None
           Potential LIKELY impact (if the                   Catastrophic        Major            Moderate             Minor            None
           incident were to be repeated)

           Likelihood of recurrence                          Almost certain      Likely           Possible              Unlikely       Rare
 Factors contributing to incident and actions to avoid recurrence
    Causal factors (checklist derived from ALARM/UCL protocol)                                 Action taken or planned & comments
  Ring codes for ALL SIGNIFICANT contributing causal factors, indicate           State what corrective actions have been taken or are planned and what has been
         the one you consider to be the MAIN immediate cause                                                 learned from this incident.
 Patient           A1    Condition
                   A2    Personal issues
                   A3    Treatment
                   A4    History
                   A5    Staff-patient relationship
                   A6    Participation in a research trial
 Individual        B1    Competence
 (staff)           B2    Skills and Knowledge
                   B3    Physical and mental stressors
 Team              C1    Verbal Communication
                   C2    Written Communication
                   C3    Supervision and seeking help
                   C4    Congruence/consistency
                   C5    Leadership and responsibility
                   C6    Staff colleagues response to incidents
 Task              D1    Availability and use of guidelines and protocols
                   D2    Availability and accuracy of test results
                   D3    Availability and use of decision-making aids
                   D4    Task design
 Work              E1    Administration systems design
 environment       E2    Notes/records design
                   E3    Building, including design for functionality
                   E4    Environment
                   E5    Equipment/supplies
                   E6    Staffing availability
                   E7    Education and Training
                   E8    Workload/hours of work
                   E9    Time factors
 Management        F1    Leadership
 and               F2    Organisational structure
 organisation
                   F3    Policy, standards and goals
                   F4    Risks imported/exported
                   F5    Safety culture
                   F6    Financial resources and constraints
 Institutional     G1    Economic and regulatory context
 context           G2    Department of Health policy and requirements
                   G3    Links with external organisations

  Checklist:             Incident coding on reverse completed
                               Copy of investigation form sent to reporter of incident

 Completed by …...………….……………………….signature ……………….…………………………..print name                                             ………………..…………………………job title

 Dept…...………………………………………………………………………………………                                                ext no…………………………. Date…………………………………………..



 Source: Risk Manager                                                   Issue date: October 2003                                       Page 15 of 17
 Status: Approved                                                       Valid until: October 2004                     Document reference: PP(03) 130
West Suffolk Hospitals NHS Trust                                               Root Cause Analysis Policy and Procedure



Root Cause Analysis Report
                                                                     Suggested Actions / responsibility /
               Contributing conditions    Possible Root Causes
                                                                                 Target date




Source: Risk Manager                     Issue date: October 2003                                         Page 16 of 17
Status: Approved                         Valid until: October 2004                       Document reference: PP(03) 130
West Suffolk Hospitals NHS Trust                                                                                                      Root Cause Analysis Policy and Procedure



Root Cause Analysis Report
                                                                                                                         Suggested Actions / responsibility /
               Contributing conditions                                Possible Root Causes
                                                                                                                                        Target date
Patient not identified as “at risk” of thromboembolism
                                                           •   No procedure for identifying and managing
                                                                                                                    Develop and implement a thromboembolism
No prophylactic anticoagulation prescribed                     patient “at risk of thromboembolism”
                                                                                                                    management protocol (prevention and treatment)
Reliance on Surgeons memory to consider need.
                                                           •   No system in place to ensure adequate ward
Failure to follow policy – Ted stockings not fitted as                                                              Revise ward stock imprest lists
                                                               supply of multiple Ted stocking sizes
unavailable

Inappropriate ward allocation
                                                           •   Mismatch between patient needs and staff skills      Review responsibility for bed allocation
Failure to recognise seriousness of condition and report       due to efficiency targets
episode to medical officer
                                                                                                                    Introduce patient dependency system
No follow-up assessment as busy with other patients        •   Mismatch between patient needs and adequate
Very brief verbal handover to ICU staff. Medical record        time for staff to complete tasks due to efficiency
                                                               targets                                              Review skill mix of nursing staff on unit
left in Obstetric unit

Nurse did not know who to call for immediate medical
assistance

Nurse thought code blue calls were only for patients
who have arrested                                                                                                   Revise Code Blue policy to include medical
                                                                                                                    emergency calling criteria and communicate to all
Inexperience of junior medical officer resulted in delay                                                            staff and clinical units
in treatment                                               •   Inadequate communication of implementation of
                                                               medical emergency team calling criteria
Consultant off site and unable to provide immediate
support                                                                                                             Provide ALS training for house medical officers and
                                                                                                                    introduce annual competency assessments
Seriousness of condition not communicated to ICU

Transfer of critical and unstable patient without
monitoring equipment or experienced staff



Source: Risk Manager                                                 Issue date: October 2003                                                                     Page 17 of 17
Status: Approved                                                     Valid until: October 2004                                                   Document reference: PP(03) 130

				
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