Root Cause Analysis for Pressure Ulceration This tool MUST be completed electronically paper copies will not be accepted.

Transcription

1 Root Cause Analysis for Pressure Ulceration This tool MUST be completed electronically paper copies will not be accepted. What is this for? This root cause analysis (RCA) tool is used when a patient acquires a category 3 or 4 pressure ulcer (as well as avoidable category 2 for inpatient areas), or a pressure ulcer deteriorates whilst in receipt of care from LPT services. This is in accordance with the policy on the prevention and management of pressure ulcers. Why use it? A root cause analysis will consider all the factors or events that led to the development of the pressure damage for that individual and determine if any measures can be taken to reduce risks of it happening again. Collective results and trends will inform the local education strategies: by understanding of the source and contributory factors associated with pressure ulcer development and take action to reduce the risks of them occurring elsewhere in the future. Who completes the RCA? All RCA s must be completed by a registered professional. The relevant professional lead (nurse or allied health care professional (AHP)) is accountable for the appropriate delegation and completion of the form. Pathway for Pressure Ulcer RCA completion and reporting: eirf Incident completed to report pressure ulceration. RCA investigation to be (using this tool by completing sections 1 to 6) completed by registered health care professional identified as responsible for the assessment / planning of care during the time frame that the pressure ulceration is likely to have occurred. Lead professional is accountable for completion of the form. Category of pressure ulcer to be verified by the Tissue Viability Nurse. TVN to offer support and guidance for ongoing care as well as accurate completion of the RCA form as required. Completed RCAs to be reviewed in each locality at Locality Analysis Group (held fortnightly week 1 and 3): Quorate Chair Manager 8a; CSM, relevant nurse team leads, registered nurse / AHP, TVN. All incidents to be reviewed within 20 days of first reporting. Confirm and challenge care provision for avoidance status of pressure ulcer to be agreed. Learning outcomes / specific actions to be agreed. Responsibility for amendments / formalising action plan to be nominated. Risk team to be informed of avoidance status of each RCA. Avoidable incidents to be recorded on STEIS. Ward Managers/ Leads are responsible for the completion of the managers form of the safeguard system. Expectation that the process will be a multidisciplinary approach. Risk team send RCA form to lead professional. RCA to be accurately completed within 10 days of the initial request. Safeguarding issues to be considered and appropriate referrals made. Care concerns must be escalated immediately. Senior Managers / Nurse Consultant TV / Lead Nurses / LSMs will attend as required. Risk team to be informed of avoidance status of each RCA. Avoidable incidents to be recorded on STEIS. Finalised forms will be reviewed at the relevant SI meetings within 40 days of first reporting. Avoidable Pressure Ulcers: RCAs to be scrutinised at SI meetings. (Held fortnightly weeks 2 and 4). (CHS will provide scrutiny for FYPC / AMH and LD). Quorate LSM / Head of Service / AHP / Lead Nurse / TVN. Unavoidable Pressure Ulcer: Sign off at Locality Governance review meetings. Learning outcomes to be tracked with locality (Divisional for FYPC / AMH and LD). Random selection of completed RCA s to be audited by lead nurses to confirm accuracy of decisions. 1 of 10

2 Section 1 Ward/ DN base Lead Investigator NHS Number Date of Birth Residential Home Date of Admission to ward or caseload Duty of Candour - please detail discussions with the patient and family or carers regarding this investigation. Patient Details Patient Initials Date of LAG Incident Number STEIS Number Training provided to home? Registered GP Relevant Past Medical History Are there any Safeguarding or Capacity concerns in respect of this patient? If yes, how have these been actioned and has a safeguarding referral been made. 2 of 10

3 Section 2 Date this ulceration discovered: Category of this ulceration: If multiple ulceration state category of most severe. If multiple ulceration evident state number of ulcers: Size of ulceration: If multiple ulceration state size of most severe. Anatomical site(s) of ulceration: If the pressure ulcer is on the heel has the circulation been assessed to the lower limb: (Yes or No state type of assessment undertaken) Pressure Ulceration Date this ulcer deteriorated: State: New or Deterioration Width (cm): Length (cm): Depth (cm): Date performed: Type of Assessment: Designation of person completing assessment: If not performed state documented reason why not: Dates this pressure ulceration photographed. Date wound assessment chart commenced for this ulceration: (If no wound assessment chart available please state why) Has the patient had previous ulceration? (If applicable state previous incident number, category and anatomical location) Review of Section 2 Pressure Ulceration (To be completed at the LAG Meeting) 3 of 10

4 Section 3 Risk Assessment Patients recently admitted to ward / caseload (within last 6 months): Skin assessment documented as completed on first contact? If No: What is the documented reason why not? (if none state not given) Date of first waterlow score completed: If not completed on first contact reason stated why not? Was the score accurate to clinical presentation? Previous Waterlow reassessments (up to last six) Date: Score: Score: Patients in receipt of continuous long term LPT care (longer than 6 months): Skin assessment documented at last contact prior to this pressure ulcer development? If No: What is the documented reason why not? (if none state not given) Date of waterlow score completed prior to this pressure ulcer development : Was the score accurate to clinical presentation? Score: Previous Waterlow reassessments (up to last six prior to this pressure ulceration) Date: Score: Review of Section 3 Risk Assessment (To be completed at the LAG Meeting) 4 of 10

5 Section 4 Date of individualised care plan for pressure ulcer prevention prior to this ulceration? Last date the individualised care plan was reviewed prior to this pressure ulceration? Date the patient has been provided with LPT patient information leaflet to prevent pressure ulceration? If appropriate, date(s) that care staff / family members have been provided with information to prevent pressure ulceration? Was delegation of care to HCA s appropriate? Care Delivery Date Documented action taken / advise given / additional comments: Additional patient information provided? Patient Involvement: What is the patient s understanding of why the pressure ulcer occurred or deteriorated? What is the patient s view on what could have been done differently? Review of Section 4 Care Delivery (To be completed at the LAG Meeting) 5 of 10

6 Section 5 Surface Was the pressure relief equipment selected appropriate to patients clinical need prior to this pressure ulcer development? Type Date ordered Mattress Cushion Other pressure relief aids (e.g. repose foot boot/ aderma pad/ heelift) Did the patient choice differ from clinical recommendations? If so, state effect on care. Was referral to AHP completed / considered to maximise equipment selection and care? Skin Inspection Date SSKIN bundle commenced prior to this ulceration? Planned frequency of SSKIN SSKIN Yes or No Date in place Comments: Date checked as in use / in working order State dates and referrals completed if appropriate. Frequency of completed skin inspections (state dates of last 6 prior to this pressure ulceration) Keep Moving Is the patient: (delete as appropriate) Fully mobile / limited movement dependent on others / bed bound / chair bound Identified (Actual / Potential) Need: Did the patient have a repositioning schedule for their specific needs prior to pressure ulceration? If not, why not? If required, date a moving and handling assessment completed & needs met? What was the repositioning frequency prior to pressure ulcer development? Who / How recorded? Date patient assessed / need identified Documented action taken / advice given / comments: (comment on frequency reviewed if applicable) 6 of 10

7 Was the repositioning schedule followed at all times (please state why not e.g. due to variance in condition / patient choice) Incontinence Does the patient suffer from continence concerns? Yes No Date continence assessment completed / needs met prior to pressure ulceration. State hygiene needs and barrier methods used prior to PU. Are these methods appropriate to meet patient need? Does the patient have moisture damage? Nutrition Date nutritional risk assessment or trigger questions completed? Has the patient been offered nutritional support (such as fortified diet advice or supplements?) Has the patient been referred to Dietician for additional advice / support? Review of Section 5 SSKIN (To be completed at the LAG Meeting) Section 6 Other Factors Please state any other contributing factors that should be taken into account: Consider the patients environment, system failures, record keeping etc. 7 of 10

8 Section 7 Five Whys Tool What factors contributed to this pressure ulcer development? Analysis of Pressure Ulcer Occurrence Keep asking why? why? why? why? Consider all relevant factors: patient factors; individual factors such as staff member / human error; environmental factors; team factors; equipment and resource staffing; communication; task factors policy or SOP; education and training. What were the critical problems or issues? Use the review of each section to focus on any identified areas for improvement. Conclusion / reason why critical issues occurred: This is the root cause of the pressure ulceration. 8 of 10

9 Section 8 LESSONS LEARNED What has the team / individual(s) involved with this patients care learnt? If no lessons learned please state None : Section 9 Overview of meeting discussion: Locality Review Meeting Comments (Divisional Review Meeting FYPC / AMH / LD) Avoidable (state STEIS number) (Complete section 9) Unavoidable with care recommendations (Complete section 8) Decision: Unavoidable without care recommendations Section 10 Quality Metrics Consider all the quality metrics (sickness level, vacancies, patient concerns, patient complaints, other reported incidents for the team within the last two months of the pressure ulcer occurring) to highlight any wider concerns and further actions. Section 11 Name of Chair 9 of 10

10 Recommended actions based on Contributory factors Agreed Action Level of Recommendation, Individual, Team, Directorate, Organisation ACTION PLAN By Whom Planned Action Start Date Planned Action End Date Resources Required Expected Outcome Evidence of Completion Current RAG Green = complete Amber = on target Red = deviation from plan 10 of 10