Root Cause Analysis for Pressure Ulceration

1 1 of 10 Version 16: December 2014 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.

2 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 . Finalised forms will be reviewed at the relevant SI meetings within 40 days of first reporting.

3 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. 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.

4 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. Risk team send RCA form to lead professional. RCA to be accurately completed within 10 days of the initial request. Category of Pressure ulcer to be verified by the Tissue Viability Nurse. TVN to offer support and guidance for on-going care as well as accurate completion of the RCA form as required. 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.

5 Lead professional is accountable for completion of the form. Ward Managers/ Leads are responsible for the completion of the managers form of the safeguard system. 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. Risk team to be informed of avoidance status of each RCA. Avoidable incidents to be recorded on STEIS. Expectation that the process will be a multi-disciplinary approach. 2 of 10 Version 16: December 2014 Section 1 Patient Details Ward/ DN base Patient Initials Lead Investigator Date of LAG NHS Number Incident Number Date of Birth STEIS Number Residential Home Training provided to home?

6 Date of Admission to ward or caseload Registered GP Duty of Candour - please detail discussions with the patient and family or carers regarding this investigation. 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. 3 of 10 Version 16: December 2014 Section 2 Pressure Ulceration Date this Ulceration discovered: Date this ulcer deteriorated: Category of this Ulceration : If multiple Ulceration state category of most severe. State: New or Deterioration If multiple Ulceration evident state number of ulcers: Size of Ulceration : If multiple Ulceration state size of most severe.

7 Width (cm): Length (cm): Depth (cm): 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) 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) 4 of 10 Version 16: December 2014 Section 3 Risk Assessment Patients recently admitted to ward / caseload (within last 6 months): Skin assessment documented as completed on first contact?

8 If No: What is the documented reason why not? (if none state not given) Date of first waterlow score completed: Score: 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: 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 : Score: Was the score accurate to clinical presentation?

9 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) 5 of 10 Version 16: December 2014 Section 4 Care Delivery Date Documented action taken / advise given / additional comments: 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 ? Additional patient information provided? If appropriate, date(s) that care staff / family members have been provided with information to prevent Pressure Ulceration ?

10 Was delegation of care to HCA s appropriate? 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) 6 of 10 Version 16: December 2014 Section 5 SSKIN Surface Was the Pressure relief equipment selected appropriate to patients clinical need prior to this Pressure ulcer development? Yes or No Comments: Type Date ordered Date in place Date checked as in use / in working order Mattress Cushion Other Pressure relief aids ( repose foot boot/ aderma pad/ heelift) Did the patient choice differ from clinical recommendations?