Clinical Incident and Quality Improvement Report
Building upon weekly activities undertaken in the tutorial sessions this assessment task involves analysing the root causes of a clinical incident and identifying evidence based quality improvement strategies to prevent recurrence of the incident.
You will be paired with another student to undertake the root cause analysis (RCA) and prepare the RCA report. Each student in the pair will be required to solely contribute to a specific component of the assessment task, for which individual marks will be awarded.
To complete the report you will be required to:
• In your analysis identify the various causes that contributed to the clinical incident
• Use an RCA template to analyse the incident and identify root causes.
• Identify action that could be taken to prevent recurrence of the event
• After analysing the root causes of the incident, each student is to work individually to:
a. Prioritise one nursing relevant strategy, and;
b. For your chosen strategy (Communication), draw upon available evidence to justify solutions or possible strategies to minimise the risk of recurrence of the incident
This evidence must be drawn from at least 5 peer-reviewed research papers on Communication from CINAHL, systematic reviews or evidence based clinical guidelines dated from 2008 onwards.
Your report should be structured under headings and include the following:
o Title: Identify the incident you have analysed
o Introduction: Clear statement about the clinical incident and the root cause analysis method.
o Root cause analysis: Completed root cause analysis template that identifies possible root causes of the incident.
o Potential interventions: Identify actions that could be taken to reduce the occurrence of the incident. Prioritise one nursing relevant strategy that is likely to result in meaningful improvement which could be implemented within the setting where the incident occurred. Justify your choice of strategy.
o Evidence base for intervention: For your chosen strategy draw upon available evidence to ensure your solution is evidence based. Evidence should be drawn from peer-reviewed research papers, systematic reviews, evidence based guidelines, or evidence based systems and processes.
o Conclusions: Draws logical and insightful conclusions about the incident and strategies to prevent its recurrence.