20/08/2017 1 NUR5326 Quality, safety and clinical governance in nursing and health care management Week 5 â€“ RCA Workshop20/08/2017 2 2 Learning outcomes ï‚§ Undertake Root Cause Analysis (RCA) of adverse events ï‚§ 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 patientâ€™s spine Second Third Fourth Fifth20/08/2017 4 4 Adverse event flow diagram â€“ consensus First Vincristine administered into the patientâ€™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 â€˜cause and effectâ€™ link (ie between the cause and the unwanted outcome) 2. Use specific and accurate descriptors â€“ avoid vague or negative descriptors in causal statements 3. Each action cause must have a corresponding conditional cause â€“ identify the preceding cause rather than the human error 4. Each procedural deviation must have a preceding cause â€“ 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 â€“ examples ï‚§ Cause and effect (preferred): â€“ 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 patientâ€™s readmission and subsequent cardiac arrest. â€“ Due to staffing shortages, routine checking by two persons was bypassed resulting in the incorrect dispensing of medications. ï‚§ Prophetic (occasionally necessary): â€“ 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. â€“ 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.