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Root Cause Analysis (RCA) Concise Investigation Report Pressure Ulcer (PU)

Root Cause Analysis (RCA) is a well-recognised way of offering a framework for reviewing patient safety incidents (also investigations claims and complaints). This process can identify what, how, and why patient safety incidents such as pressure ulcer(s) have happened. Analysis can then be used to:

 Identify areas for change;  Develop recommendations, and;  Look for new solutions.

Ultimately, they should help prevent incidents from happening again.

1. Incident number: ……………………………………………………………………... 2. Date safeguarding alert completed: ……………………………………………… 3. Report author: ………………………………………………………………………... 4. Job title: ……………………………………………………………………………… 5. Date report completed: ……………………………………………………………

6. Improvement plan completed and attached (Appendix 1) Y / N

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IMPORTANT NOTES – PLEASE READ BEFORE COMPLETING FORM Type in RED is for guidance purposes only but can be used in conjunction with relevant information. The aim of this template is to guide the investigation of how the pressure ulcer(s) developed and to recognise any lessons learnt to ensure mitigating risks can be identified to reduce the risk of a similar event from occurring. Please answer all questions together with any supporting information in BLACK. If not relevant to investigation insert N/A

1.

Concise Incident description 

Name of service: …………………………………… (At time of incident)

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Type of service: …………………………………….. (E.g. nursing, domiciliary, residential)

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Name of service user General Practitioner………………………………..

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Date PU identified: …………………………………………………………

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Time PU identified: ………………………………………

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PU category: Category 3

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Brief description of incident (Factual)

Category 4

………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… 

Actual effect on service user and/or service (How has this impacted on their condition) ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… Page 2 of 12

 Information and evidence gathered (E.g. review of incident form, care record, medical records, protocols, policies, training records, appraisal records, national best practice guidelines, clinical studies, phone records, BNF, map of site, photographs, equipment maintenance schedules etc.) - …………………………………..

-…………………………….. .

-……………………………………

-………………………………

-……………………………………

-……………………………...

-……………………………………

-………………………………

 Involvement and support provided for the service user involved (How have they been informed of the incident? What has been discussed with the service user/relative/those close to them?) ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ……………………………………………………………………………………………….. ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………..

Limitations to this report ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………..

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2.

Chronology (factual)

Provide a brief timeline of events leading up to the pressure ulcer identification Date:

Details:

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3.

Analysis of treatment

a. Past medical history  Has there been a recent change in medical condition? Y / N  List co-morbidities ……………………………………………………………………………………………………………... ……………………………………………………………………………………………………………. …………………………………………………………………………………………………………….  State which of the following are applicable □ Skin or wound infection □ Other infection □ Pyrexia □ Anaemia □ End of life □ Previous pressure ulcer damage □ Other specify (such as peripheral vascular disease, diabetes, immobility, CVA, steroids, weight loss) …………………………………………………………………………………………………………

b. Summary of pressure ulcer risk assessment and care  Please state dates of risk assessments………………………………………………………………..  Type of risk assessment tool used ……………………………………………………………………  Overall risk level at time pressure ulcer identified…………………………………………………… (e.g. No Risk 15) c. Key points of preventative plan – (state if in place and specific details)  Did the service user have a pressure ulcer preventative plan in place? (e.g. SSKIN bundle or specific pressure ulcer care plan) Y / N  Surface Was the preventative plan explicit in what equipment was required? Y / N (State mattress and/or cushion) ……………………………………………………………………………  Skin Was a skin inspection undertaken as per the assessed frequency? Y / N

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 Keep moving. -

State repositioning regime at time of identification of PU …………………………………………

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State Waterlow score at time of identification of PU ……………………………………………

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Was the Waterlow score completed on admission to care facility? Y / N

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Was the Waterlow score updated monthly or as per clinical condition dictated? Y / N

 Incontinence -

Date of incontinence and moisture assessed: ……………………………………………………… (date/state if no problems identified)

 Nutrition. -

Nutrition assessed Y / N Date completed …………………………………………………………

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Were any risks/issues highlighted …………………………………………………………………..

………………………………………………………………………………………………………………. -

Level of risk at time pressure ulcer identified ……………………………………………………..

(0 – 6 Low Risk, 7 – 13 Medium Risk, 14 – 21 High Risk)

d. Reporting -

There was / was not evidence of late reporting (delete as applicable)

e. Mental Capacity  Did you need to undertake a mental capacity assessment in relation to care received? Y / N  If so did the person’s capacity influence decisions made in respect of pressure area care? Y / N

f. Pressure ulcer history  Has the service user had a pressure ulcer previously? Y / N  Is it the same location as current pressure ulcer? Y / N

g. Current Treatment  Is the service user responding to treatment? Y / N  Has a photograph been taken of the wound? Y / N

Date: ………………………………

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4. Good practice Points in the incident or investigation process where care and/or practice had an important positive impact and may provide valuable learning opportunities. (E.g. good practice, involvement of the patient, staff openness etc.) ……………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………… 5. Care Delivery, Contributory factors, Systems, Recommendations Care/service delivery Problems (CPD/SDP) CDP – is a problem that arises in the process of care. (be precise) SDP – acts or omissions that are identified during the analysis of the service users patient safety incident but are not associated with direct provision of care (be precise)

Contributory Factors

Systems

The fishbone diagram (appendix (e.g. policies 2 ) will assist you to identify supervision) contributory factors

Recommendations and 2 sorts of recommendations you will be making; (1) To improve existing systems which are not working as well as they might. (2) To implement missing systems

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Care/service delivery Problems (CPD/SDP)

Contributory Factors

Systems

Recommendations

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6. Root Cause

Was the pressure ulcer risk evaluated correctly and in a timely Yes manner?

No

Was the pressure relieving mattress/ interventions correct for the risk Yes identified?

No

Did the service user use the equipment supplied?

Yes

No

Did the service user have skin inspections completed as required on Yes the bundle?

No

Was the service user repositioned as appropriate to the risk Yes identified? And as condition allowed? (State if service user declined or was unable to maintain position changes and ensure this is reflected in the analysis section b)

No

Were the nutritional and fluid supplements correct for the identified Yes nutritional score?

No

Was the impact of all interventions monitored & evaluated and Yes recorded in the service user’s notes?

No

Has the service user complied with assessments and the agreed plan Yes of care? (State if service user does not have full mental capacity and ensure this is reflected in the analysis section e)

No

Prior to the pressure ulcer development has the service user’s Yes condition remained stable?

No

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7. Lessons learnt ………………………………………………………………………………………………… ………………………………………………………………………………..………………… ……………………………………………..…………………………………………………… 8. Arrangements for shared learning Describe how learning has been or will be shared with staff and other organisations (e.g. through bulletins, newsletters, team meetings, professional networks, reporting, etc.) ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………

9. Appendices Appendix 1 – Improvement Plan Appendix 2 – RCA investigation – Fishbone Diagram tool Developed: April 2015 Next review date: April 2016 Developed by; Quality and Safety Herefordshire Clinical Commissioning Group (HCCG)

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Appendix 1

Improvement plan

SIRI/Frameworki number ………………………………………

Recommendations

Incident form number: ………………………………….

Actions required to implement recommendations

By Whom

By When

Date completed and evidence of implementation

1

2

3

4

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Root Cause Analysis Investigation Patient factors: Clinical condition Physical factors Social factors Psychological/ mental factors Interpersonal relationships

Fishbone Diagram – Tool

Appendix 2

Individual (staff) factors:

Task factors:

Communication factors:

Team factors:

Physical issues Psychological Social/domestic Personality Cognitive factors

Guidelines/ procedures/ protocols Decision aids Task design

Verbal Written Non-verbal Management

Role congruence Leadership Support + cultural factors

Problem or issue (CDP/SDP)

Education + Training Factors: Competence Supervision Availability / Accessibility Appropriateness

Equipment + resources: Displays Integrity Positioning Usability

Working condition factors: Administrative Design of physical environment Environment Staffing Workload and hours Time

Organisational + strategic factors: Organisational structure Priorities Externally imported risks Safety culture

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