File attached ,PLEASE USE FLORENCE LILIAN THOMAS__BROKEN NECK pdf
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. b. For your chosen strategy, draw upon available evidence to justify solutions or possible strategies to minimise the risk of recurrence 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 brief 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 occurred. 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 recurrence 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 order · Place a tick or cross only in the category column Item No. Description of root cause/contributory factor 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 (Barriers) 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 surrounded 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 blue 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 ru 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 relevant 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 (barriers) at each step might stop the problem from occurring again. 4. A cause and effect diagram can then be constructed.This will assist in formulating the causal links and error 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 brainstorm 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 page 5 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 or 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 referred to management to be 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 related 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 barriers to communication, and insight into the organisation’s culture with regard 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 booked 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 page 7 Knowledge/Skills/Competence These are questions that help assess issues related to routine job training, special training, and continuing education, including the timing of that training.Training issues may concern application of approved procedures, correct 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) arrived this week to start a rotation at your facility. A laboratory error 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 page 8 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 arrhythmia, becomes 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 page 9 Equipment These are questions to help evaluate factors related 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 relate 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 risk, 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 regulations. 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