20/08/2017 1 NUR5326 Quality, safety and clinical governance in nursing and health care management Week 5 – RCA Workshop20/08/2017 2 2 Learning outcomes  Undertake Root Cause Analysis (RCA) of adverse events  Identify the key focus and components in formulating causal statements following RCA of adverse events20/08/2017 3 3 Adverse event flow diagram First Vincristine administered into the patient’s spine Second Third Fourth Fifth20/08/2017 4 4 Adverse event flow diagram – consensus First Vincristine administered into the patient’s spine Second Third Fourth Fifth20/08/2017 5 5 Fishbone diagram template20/08/2017 7 7 Five rules of causation 1. Causal statements must clearly show the ‘cause and effect’ link (ie between the cause and the unwanted outcome) 2. Use specific and accurate descriptors – avoid vague or negative descriptors in causal statements 3. Each action cause must have a corresponding conditional cause – identify the preceding cause rather than the human error 4. Each procedural deviation must have a preceding cause – identify the preceding cause rather than the procedural violation 5. Failure to act is only causal when there was a pre-existing duty to act20/08/2017 8 8 Causal statements – examples  Cause and effect (preferred): – The lack of staff training on the management of patients with chest pain resulted in the patient being discharged without appropriate investigations being completed, which contributed to the patient’s readmission and subsequent cardiac arrest. – Due to staffing shortages, routine checking by two persons was bypassed resulting in the incorrect dispensing of medications.  Prophetic (occasionally necessary): – The unavailability of guidelines for the management of chest pain in the emergency department will continue to contribute to the delivery of sub-optimal care. – The absence of effective training for nurses on the use of the different IV pumps in the health service will continue to contribute to the incidence of medication dosing errors.