Root Cause Analysis (RCA) of Clinical Incidents

Note: You are required to attend a briefing, 2pm - 4pm which falls on the first Monday of the month.

Synopsis
What
Root Cause Analysis (RCA) is a structured method to analyse a clinical incident *.
Participants will be attached to Medical Affairs (Clinical Governance) to investigate a clinical incident reported in Electronic Hospital Occurrence Reporting (eHOR) system or an M&M case.

Objectives
The participants will learn how to apply RCA tools to investigate a clinical incident.
Identify underlying system issues in healthcare processes that led to the incident and recommend risk reduction strategies.

Time Commitment:
3 hrs : briefing on quality tools and case assignment discussion with RCA facilitator
~8 hrs (flexi time) : case investigation, analysis, draft RCA report

Applicable Quality tools
Process Mapping, Cause and Effect Diagram, 5 Whys, Gap Analysis, Hierarchy of Controls
Use of specific tool will be based on its suitability in a particular incident

Deliverables:
Full RCA Report- submission within 10 working days after start of attachment.
Complete an evaluation survey (5-10 mins) to be submitted to MA(Edu)

*A clinical Incident is an event or circumstance during health care which could have resulted, or did result in harm to a patient