Root Cause Analysis Report

Region: ------ City: -------

Facility Name: ABCD
Patient Name: AAAA Patient MR #: 12345
Patient Age: 70 Y Patient Gender: F
Date of Event: 30 Dec 2017. Time of Event: (11: 34 am/pm)

Type of Event: Unexpected Death

Event Resulted in: × Death
o Physical Harm
o Psychological Harm
Harm details: Death
Date Investigation 3rd January 2018 Date Investigation 20 January 2018
Started: Complete:
Date Event Discovered: 30 Dec 2017 Date Reported to 1st Jan 2018
MOH:
Brief Description Date of admission: 19/11/2017
70y old female patient admitted to W1 through ER, the patient came to ER
complaining of dyspnea for 6 days (acute in onset, even at rest).
History:
DM, HTN, CHF, CKD, diabetic retinopathy, diabetic nephropathy, old CVP.
Hospital Course:
The patient has been admitted to W1, W2, and ICU. According to the progress
note, the patient admitted to ICU shocked (cardiogenic, and septic shock),
with recent NSTEMI-AKI. The ICU course was prolonged complicated ICU
course. The patient also has a tracheostomy and was on ventilator (failure to
ex-tubate 5 times). After discharge from the ICU
On 30 Dec the patient had bleeding via trachedomy coded and announced dead
at 11: 34 pm.

- Day1: The patient came to ER with complaints of dyspnea for 4 days

- Admitted to the ward as CAP (community acquired pneumonia).
- Day 2: Had restlessness SOB tachycardia and tachypnea
- Admitted to ICU.
- Day 29 in ICU: Intubated (tracheostomy) No complication on post
procedure period.
- Day 35: Discharged from ICU to male medical (no bed in female
medical).
- Day 36: Hematuria & minimal bleeding in respiratory secretions.

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 - Day 37: Transferred to female medical Bleeding not resolved
completely.
- Day 40: Bleeding from tracheostomy site and tracheostomy tube, caused
respiratory arrest. Time of Events: 23:34 hr.

Care Delivery - Delay in patient referral to ENT - Patient has been referred to ENT
Problems: on the fourth day since the bleeding signs started.
- Inappropriate use of double antiplatelet therapy in the presence of
continuous oozing blood from tracheostomy.
- The nurses and RT (respiratory therapists) did not communicate
the bleeding findings to the physician.
- The physicians did not handover the bleeding to other physicians.

Contributory Factors: - Patient Factors: Multiple Comorbidities.

- Individual Factors: (inexperienced staff not trained).
- Team factors: Communication between nurse -physicians and RT and
Physician.
- Work Environmental Factors: Staffing level for physicians and RT.
- Organizational and Strategic Factors: lack of policies enforcing handover
between physicians.
- Task Factors: No Guidelines for tracheostomy Care.

Root Cause/s: - Team Factors.

- Organizational and Strategic Factors: lack of policies enforcing handover
between physicians and RT to report critical findings.

Recommendations: - To establish a standardized handover system in the Medical-SD units.

- To enhance communication between RT and physicians.
- To enhance communication between nurses and physicians

2- Investigation Team:
Role Name Received training on
RCA*
RCA Team Leader: Dr. Hassan Ahmad Yes
Quality/Patient Safety Expert: Rph. Ali Suliman Yes
Senior Management: Dr. Mohammed Al Hamad Yes

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Member: Jenna Mark Yes
Member: - No
* or Have been previously involved in RCA

3- Source of Information used for the Investigation:

Source of Information Details

o The medical record o Physician Assessment.
o Progress Note.
o Medication Sheets.
o Nurses Notes.
o Respiratory Therapist Notes.
o Dialysis Sheet.

o Documentation and forms related to the Example:

incident (e.g. protocols and procedures) - Handover Policy.
- Patient Assessment for RT: does not indicate the
need to inform the physicians and nurse when there are
critical findings.
o Immediate statements and observations. -

Source of Information Details

o Interviews with those involved in the Badge Number and Job title of Interviewed Personnel:
incident
BN Job title
12345 ICU consultant
11111 IM Staff
Physician
2222 Staff Nurse

o Physical evidence (e.g. ward layout NA

schematics, etc.)
o Equipment involved in incident NA

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 o Information about relevant conditions RT has 3 staff/shift covering all wards unit.
affecting the event (e.g. staff rota,
availability of trained staff, etc).

4-Narrative Chronology of the event: - See documentation table.

5-Care Delivery Problems and Contributory factors

Care Delivery Problems Contributory factors Root Cause:

Fundamental Contributory factor
Delay in patient referral to - Individual Factors - Team Factors.
ENT - Patient has been (inexperienced staff not - Task Factors.
referred to ENT on the fourth trained).
- Work Environmental Factors:
day since the bleeding signs
Staffing level for physicians
started. and RT.
- Team factors: team structure
Communication between
junior and senior physicians.
- Task Factors: No Guidelines
for tracheostomy Care.
Inappropriate use of double - Patient Factors: Multiple - Individual Factors
antiplatelet therapy in the Comorbidities. (knowledge).
presence of continuous oozing - Individual Factors
(knowledge).
blood from tracheostomy.
The nurses and respiratory - Team factors: - Team Factors: verbal
therapists did not Communication between communication.
communicate the bleeding nurse -physicians and RT and
Physician.
findings to the physician.

The physicians did not - Organizational and Strategic - Organizational Factor no

handover the bleeding to Factors: lack of policies handover system (policy and
other physicians. enforcing handover between monitoring process).
physicians.
- Work Environmental Factors:
Staffing level for physicians.

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 6-Action plan

Filed: Recommendation 1 Recommendation 2

Contributory Factor: Team Factors: Communication between - Team Factors: Communication
nurses/RT and physicians between physicians

Actions to Address - To have the nurse lead the medical - To establish a handover
Factors: round. system (policy, training and
- To have the RT attend and monitoring).
participate in the morning round. - To encourage the junior
- To update the RT assessment physicians, speak up in the
policy. medical round.
Level of - Team: Medical Units. - - Department of medicine.
Recommended action
(Individual, team,
organizational,
directorate):
By whom: - Medicine Chairman. - - Medicine chairman.
- Medical Ward Nurse Manager.
- RT Manager.
Due when: - 1 month for the policy. - 1 month for the policy and
- Immediate for participation in the training.
round. - Immediate for physicians'
involvement.

Resource - - - Time, and training.

Requirement:
Evidence of Audit of the round. - Policy approval and
completion: dissemination.
- Audit of the handover.

Completion sign off:

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 Flow Chart:

Patient started to Action Yes, Hold Heparin and

observation-26 Dec
hematuria & Blood Taken
in sputum
26 Dec
Patient had moderate
blood in respiratory
Weekend secretions
27-28 Dec
Indicated systemic
problem of (bleeding)

Bloody secretions No Action

Actio increased today
n Taken
29 Dec
Taken

Monitor Bleeding
29 Dec Problem Blood increased
continued around 19:30 hr.
Fresh mixed with
clotted
30 Dec 2013

Minimal blood in Dialysis done

secretions continues
30 Dec
Delay one Action
hour Taken

ENT Consultation
Respiratory Collapse Arrived around 22:25
And death HR Referral to ENT
21:00HR

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 Documentation:
Date Doctor Note Nurse Note RT note
26 Dec Stable Hbg. Patient Has Hematuria Tracheal clean no difficulty, small thick
Day -Had minimal hematuria. Dr order to hold heparin yellow blood stained, good cough stimulated.
-Had minimal blood in septum.

26 Dec Bleeding not mentioned in the Bleeding not mentioned in Tracheal clean no difficulty resistance in
Night documentation. the documentation. passing catheter moderate loose white yellow
blood stained, poor cough stimulated.

27 Dec Bleeding not mentioned in the Suctioning done with Bleeding not mentioned in the
Day documentation. moderate sticky, slight documentation.
blood-stained sputum
No focus of Dr. informed

27 Dec Bleeding not mentioned in the Bleeding not mentioned in Nebs given with tracheal suctioning done
Night documentation. the documentation. obtaining large loose thick yellow secretion,
no resistance notice.
28 Dec Bleeding not mentioned in the Suctioning done with No difficult resistance in passing catheter,
Day documentation. bloody sputum large thick yellow blood stained, and good
Dr. informed by SN & cough stimulated.
documented by SN,
No order & no Dr's note.
28 Dec Bleeding not mentioned in the Handover by staff nurse, Tracheal clean no difficulty resistance in
Night documentation. noted bloody secretion passing catheter, large thick loose white
blood stained, and good cough stimulated.
Atrovent 0.5 mg also had given, trach-care
done, suctioned thick to lose blood-stained
secretion.
29 Dec Bloody secretions increased today Suctioning done with blood Trachea cleans no difficulty, small thick
Day Heparin hold due to bleeding stained secretion blood brown good cough stimulated, tracheal
Monitor bleeding Informed team during round care done.
at 10:20hrs. Nurses note In breath sound post: clear with coughing
documented. clears with suctioning.
Dr's order to monitor
bleeding.

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