Root Cause Analysis Pandora's Box or Treasure Trove by kjm12717

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									     Root Cause Analysis:
Pandora's Box or Treasure Trove?
               Jill Reyment
                Paul Curtis
      Greater Southern Area Health Service
        Experience to Date

• NSW Health – Safety Improvement
  Program
• 49 completed RCA’s
• Varied and across disciplines, services
  and sites
Greater Southern Area Health Service
Greater Southern Area Health Service
  •   Population        468,000
  •   Area              166,000 sq km
  •   Total staffing    7,370 (persons)
  •   Number of sites   47 Hospitals
                        95 CH sites
  •   Outpatients       1,540,000
  •   In-patients       87,000
  •   Number of beds    2090
  •   Budget            $650,000,000
   Case Study – Oscar Russell
• Aged 49 with Depression
• Presented to ED 22nd Dec and was
  discharged
• Presented 1900 Christmas Eve with
  suicidal ideation
• s/b RMO who d/w psychiatrist
  • High risk
  • Management plan
  • Voluntary patient
• Bed unavailable so kept in ED
• Night RMO delayed – missed handover
       Case study (cont.)
• Oscar wanted to leave 0100
• Assessed by night RMO
  • Notes unavailable - renovations
  • Low risk
  • Discharged
• Next day – friend rings “worried” – low
  priority given
• 48 hours found deceased in car

• Staff felt night RMO to blame
                    RCA
• Centralised with Patient Safety Manager
  to facilitate
• Emphasis on team selection
  •   Psychiatrist
  •   ED nurse
  •   ED doctor
  •   Director of Clinical Services
• Wide consultation regarding the case
  • Staff involved given opportunity to “tell their
    story”
             RCA (cont.)
Findings
   • Poor handover processes
   • Opportunities to intervene after
     patient left but missed
     • MH liaison nurse not notified
     • Call centre referral forwarded to closed
       service
     • Community mental health functioning
       but no one aware
  • Psychiatrist not consulted before
    discharge
            RCA (cont.)

Recommendations
  • Improve handover processes
  • Consult psychiatrist before discharge
  • Improved communication between
    community mental health and ED
  • Call centre to review client
    assessment
   Discussions with relatives
• Met with Oscar’s mother
  • Explained what happened – better
    information
  • Explained recommendations – better
    link to causes of incident
  • “Why weren’t the new processes
    already in place?”
• Follow up visit
  • Explain progress of recommendations
           RCA Treasures
•Clinician involvement
•Improved recommendations through
wide consultation
•Staff surprised at no. of process
failures and individuals not targeted
•Coroner involvement
•Open disclosure
•Process to ensure accountability
•Better support for staff
         Pandora’s Box

• Time to completion
  • Implement recommendations more difficult
  • Staff moved on
• Complex process
  • flow chart --> causal statements
• Accountability v/v system issue
    Pandora’s Box (cont)
• Too many
• Unrealistic
• “Hobby horses”
        Treasure trove because:
•   Robust process for investigation
•   Reduced fear of speaking with relatives
•   Accountabilities transparent
•   Staff support
•   Identifies areas for CPI efforts
•   Leverage for quality program

								
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