6NH068: Detailed Assignment Brief
You will develop a written root-cause analysis (RCA), based on a critical incident (case study) provided in the module Canvas topic, in which you will demonstrate how you would define, analyse, improve and control the circumstances around the chosen critical incident from adult nursing practice.
You will choose a RCA model/framework from those provided in the Canvas topic to organise your work. Using the structure set out below, you will identify, critically analyse and reflect on the factors that may have contributed to your chosen incident, and then make appropriate recommendations for enhancing the safety and quality of care of this aspect of clinical practice in the future. You are required to underpin your work throughout by making reference to appropriate literature.
LO1: Apply the principles of risk management in maintaining a safe care environment
LO2: Critically reflect on near misses, critical incidents, major incidents and serious adverse events
LO3: Critically explore how human factors can influence and impact upon behaviour within teams and the way in which this can affect health and safety
LO4: Appraise and advocate methods used to instigate positive change to promote safety and quality of care
All learning outcomes must be achieved to successfully pass the module.
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STRUCTURE FOR YOUR ROOT-CAUSE-ANALYSIS
Introduction (indicative 200 words)
Provide a brief introduction to your work. You should identify:
· The chosen clinical incident (case study). Your summary of the case study needs to be factual.
DO NOT simply repeat the information given on Canvas. Identify the following:
-Case study number
-Patient name/age
-Past medical history (if known)
-Any family?
-Reason for admission
-What happened – very briefly e.g. incorrect placement of NG tube
-Outcome of care episode
· The chosen RCA model/framework
· Your findings
· Recommendations for change
The introduction should provide a very brief summary which allows the reader to quickly get an understanding of the complete assignment. In this section, you should use references to support your work. This section provides an overview, and in the main body of the assignment, you go into more detail.
Justification of chosen model/framework (contributes to LO1-4) (indicative 500 words)
It may be useful to provide a brief overview of what a RCA is and the purpose of undertaking one-demonstrating the link to patient safety and quality of care.
You then need to justify the chosen RCA model/framework used for your investigation.
This should include comparing and contrasting with other models/frameworks in order to explain how your choice best aligns to your analysis of the case study. Supporting references needed.
· You can use more than one framework if you choose e.g. 5 whys initially then fishbone. You need to use appropriate academic evidence to justify the choice of your model(s)
· You also need to identify at least one other model, and using appropriate evidence demonstrate why you did not choose that particular one
When you apply your model(s) you will find that you identify a lot of contributing factors. You do not have scope within the assignment to discuss all of these.
· Provide an appendix which demonstrates your chosen model and all the contributory factors that you have identified. You can then choose which ones you want to prioritise and focus on.
It may be useful to acknowledge that a ‘real life’ RCA would involve a multidisciplinary team and identify the implications of only one person undertaking an analysis.
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STRUCTURE FOR YOUR C Root-Cause Analysis (continued)
Discussion (LOs 1, 2 and 3) (indicative 1800-2000 words)
In the main body of the assignment, apply your chosen RCA model/framework; this will inform the structure of this section.
· From the list of contributory factors identified in your appendix, identify and prioritise a minimum of three factors that may have led to the incident
· Critically analyse the impact/effect of these factors, in relation to risk management, human factors and the care environment
· Ensure appropriate supporting literature is used throughout
Some things to consider (this is not an exhaustive list):
· Principles of risk management – in your case study were these evident or missing? Were correct processes followed? What risk assessments were undertaken, or should have been undertaken?
· Human factors – was the incident as a result of individuals making deliberate ‘violations’? Were the systems and processes such that the individual inevitably made an error? Was the healthcare team involved an effective team? If not why? What impact did this have on the care given and patient outcomes?
Revisit the resources on Canvas, particularly with regard to Risk management and Human factors.
If you feel there are ‘gaps’ in the information given, DO NOT ‘make things up’ or try to ‘fill the gap’ with assumptions. If you feel there is important information missing you could identify what information you would require, and say why (using evidence to support your assertions).
Remember that part of the RCA process links to Duty of Candour. How will this be applied in your case study, and why?
Recommendations (LO 4) (indicative 800-1000 words)
Here, you will identify your proposed recommendations to lead to positive change directly from the chosen incident. Your recommendations should relate to the issues you prioritised in your discussion. Consider:
· How might you instigate the changes – identify an appropriate model e.g. Plan; Do Study; Act (PDSA) cycle, and use this to support your proposals.
· What factors might affect your ability to make such changes.
You should appraise and advocate methods used to instigate positive change to promote safety and quality of care. How will these methods prevent future occurances?
You should support this section with appropriate references.
Conclusion (indicative 200 words)
The conclusion is a short section that ‘ties together’ your work. You need to make sure you don’t introduce new information in this section- remember you are drawing together what you have said in the main body of the assignment.
