Clinical Governance is the term used to describe a systematic approach to maintaining and improving the quality of patient
care within a health system. It is about the ability to produce effective change so that high quality care is achieved. It
requires clinicians and administrators to take joint responsibility for making sure this occurs.
A critical incident can be any of the following:
•an adverse event (where ‘harm’ was caused to a patient or colleague),
•a sentinel event (involving mortality and significant morbidity), or
•a near miss (where harm was narrowly averted),
•a critical incident can also be where an unexpected positive outcome was observed.
All critical incidents result from a series of underlying/predisposing factors resulting usually from human error, and
deficiencies in systems and processes or procedures. When a series of factors line up in a certain way, an adverse event
results. If the sequence of events is correctly analysed, the investigator can identify its origin and key points in the
sequence, this allows the investigator to design mitigation strategies that can effectively stop that same sequence from
recurring.
The task in this assignment is to:
Write a ‘Formal Investigative Report’ about a real-life critical incident that has occurred.
The student should use a critical incident that has been published on the Internet or via any other public domain.
Please use the below as a guide of what to include in this report, the marking criteria will also help guide you.
Introduction/Background to the Incident: A short introduction including what the report is about followed by a brief
background to the critical incident.
Data: Critically examine the case to identify and explore all the predisposing factors that lead to the outcome, these
factors are the ‘root causes’. This information needs to be supported by a flow chart with annotations to present the
complex details of the incident in an easy to view format.
Analysis: Analysis of the information presented in the ‘data’ section can be referred to as a ‘root cause analysis’ (RCA).
The predisposing factors are explored in regards to why they existed and how they lead to the incident. Any relationships
between the factors is also explained. Use a ‘patient safety model’ diagram to demonstrate the factors that were the root
causes that lead to the incident and to identify factors that if mitigated would have prevented the incident from
occurring.
NB: Root causes always form one or more chains of events. If a RCA is conducted correctly it will lead you back to the
origin of this chain of events. If you can eliminate one or more of the root causes or break the chain of events you can
prevent the same type of adverse event from recurring. A patient safety model is a conceptual construct that guides the
investigator in the process of analysis.
Discussion: In this section of the report current evidence-based peer reviewed literature is explored in relation to the
incident and the root causes of the incident to develop a deeper understanding of the why the incident occurred, what
should have happened and how it could be prevented in the future. The ANMAC competencies should be discussed in relation
to professional best practice with two (2) relevant competencies being explored further. The literature discussed needs to
be of a high quality and be current.
Recommendations: Evidence-based recommendations are made, which if implemented correctly would prevent the same incident
from occurring again. Literature which supports the recommendations needs to be presented, otherwise the report will have
little credibility. Any recommendations must address the identified pre-disposing factors, in particular the ‘root causes’
and explain how the recommendations will mitigate these factors using a clear and logical approach.
Rationale
A Registered Nurse is expected to be able to reflect on and analyse their clinical practice and to be aware of the systems
in which they function. It is important to be aware of and involved in quality improvement processes. This assessment task
will allow the student to explore these quality assurance processes and to gain an understanding of the importance of
their role as a Registered Nurse in regards to patient safety.
This assignment addresses the following learning objectives: 2, 3, 4, 5, 6, 11, 12, 13, 14
Marking criteria
Dimension High Distinction Distinction Credit Pass Unsatisfactory
Report structure and presentation
(Possible marks 5) Marks 4-5
The report is logically presented with clear and concise professional language.
The use of effective flowcharts or diagrams which easily demonstrate the intended information and enhance the report.
The report adheres to the presentation requirements in the Subject Outline.
Overall the report is excellently written with a systematic and logical presentation and would be suitable for
publication. Marks 3- 4
The report is systematic and utilises professional language.
Flow charts and diagrams are used which are easy to interpret and linked to the report.
The report adheres to the presentation requirements in the Subject Outline.
The report is well written and set out at the level of an investigative report.
Marks 2.5-3
The report is clearly structured and aligns with the table of contents.
A flow chart or diagram has been used which is relevant and can be interpreted easily.
The report adheres to the presentation requirements in the Subject Outline.
The report is well written with no spelling or grammar errors.
Marks 2.5
The report has some structure.
A diagram or flow chart is used and labeled but could be linked to the report better
The report mostly adheres to the presentation requirements in the Subject Outline.
There are few spelling, grammatical or formatting errors.
Marks 0-2.5
The report has minimal structure and lacks sign-posting.
Diagrams are not related or linked to the report or are difficult to interpret
The report does not adhere to the presentation guidelines in the Subject Outline.
The font type and size vary and there is evidence of ‘cutting and pasting’ information from other written sources.
Multiple spelling, grammar or formatting errors
Written in ‘first person’.
Introduction & background of the critical incident
(Possible marks 10) Marks 8-10
The introduction is clear, concise and gives a logical overview of the issue and what will be discussed.
The background to the critical incident is clear and concise with a clear summation of the events and outcome. Marks 7-8
The introduction is clear, concise and gives a logical overview of the issue and what will be discussed.
The background to the critical incident clearly outlines the events and outcome.
Marks 6-7
The introduction introduces the critical incident and gives an overview of what will be discussed.
The background to the critical incident is outlined.
Marks 5-6
The introduction gives an overview of what will be discussed but lacks clarity and has some formatting errors.
The background to the critical incident is lacking in the main points or has been poorly summarised. Marks 0-4
An incoherent introduction or no introduction.
The background to the critical incident is poorly described or copied directly from the original reporting document, or is
too long.
Data
(Possible marks 10) Marks 8-10
A clear and concise but comprehensive description of all the factors leading to the critical incident enhanced by an
exceptional flow chart which clearly demonstrates the complex details of the incident in a easy to understand format.
Marks 7-8
A comprehensive description of the factors leading to the critical incident enhanced by a well designed flow chart which
clearly demonstrates the complex details of the incident in a easy to understand format.
Marks 6-7
A clear description of the main factors leading to the critical incident enhanced by an flow chart which clearly
demonstrates the complex details of the incident in a easy to understand format.
Marks 5-6
A superficial description of the factors leading to the critical incident with a flow chart that demonstrates these
factors. The flow chart may be of poor quality or may be difficult to interpret.
Marks 0-4
A poor description or a poor understanding of the factors leading to the incident and/ or missing important factors.
No flow chart or a flow chart that is very difficult to interpret.
The data or flow chart from the critical incident has been copied directly from the original reporting document.
Analysis
(Possible marks 10) Marks 8-10
Insightful and logical interpretation of all the factors that were the root causes that lead to the incident.
Inter-related factors identified.
Interpretation of factors that if mitigated would have prevented the outcome.
An appropriate patient safety model is used which clearly demonstrates the findings and displays a high level of logical
thought.
Marks 7-8
Logical interpretation of the factors that were the root causes that lead to the incident.
Interpretation of factors that if mitigated would have prevented the outcome.
An appropriate patient safety model is used which clearly demonstrates the findings.
Marks 6-7
Interpretation of the factors that were the root causes that lead to the incident.
Identification of factors that if mitigated would have prevented the outcome.
An appropriate patient safety model is used which demonstrates the findings.
Marks 5-6
Identification of the factors that were the root causes that lead to the incident.
Minimal interpretation of the data.
A patient safety model is used to demonstrate the findings, however this may be difficult to interpret or be of a poor
quality.
Marks 0-4
No reference to any root causes that lead to the incident.
Incoherent or a lack of interpretation of the data
No patient safety model has been used, or the model used is not easily related to the data.
The model used is a demonstration model and has not been applied to the incident.
Missing data, links or relevant information.
The analysis or patient safety model of the critical incident has been copied directly from the original reporting
document.
Discussion
(Possible marks 15) Marks 13-15
Comprehensive and logical exploration of the main root causes of the incident in relation to current evidence based best
practice guidelines and 2 relevant and well related ANMAC competencies.
High quality literature is explored to discuss the root causes in relation to other similar cases.
Marks 11-13
Logical exploration of the main root causes of the incident in relation to current evidence based best practice guidelines
and 2 relevant ANMAC competencies.
High quality literature is used in the discussion.
Marks 9-11
Exploration of the root causes of the incident in relation to current best practice guidelines and 2 relevant ANMAC
competencies.
High quality literature is used in the discussion.
Marks 7.5- 9
Discussion of the root causes of the incident in relation to current best practice guidelines and 2 ANMAC competencies is
limited.
Acceptable literature is used in the discussion.
0-7
Incoherent or lacking adequate discussion of the root causes of the incident.
No reference to ANMAC competencies or best practice.
Lacking adequate reference to current literature.
The discussion of the critical incident has been copied directly from the original reporting document.
Recommendations
(Possible marks 10) Marks 8-10
All recommendations are clearly and concisely presented and logically and comprehensively linked to the predisposing
factors and mitigation strategies.
Recommendations are achievable and if implemented would prevent the same type of incident occurring again.
High quality literature used expertly to support the recommendations. Marks 7-8
All recommendation are clearly presented and coherently linked to the predisposing factors and mitigation strategies.
Recommendations are achievable and if implemented would prevent the same type of incident occurring again.
High quality literature used to support the recommendations.
Marks 6-7
All recommendations are linked coherently to the predisposing factors
Recommendations are achievable.
Current literature used to support the recommendations.
Marks 5-6
Superficial recommendations suggested that are lacking linkage to the predisposing factors.
Recommendations presented are achievable however they may only assist in lowering the risk.
Some literature has been used to support the recommendations but it is not of a high standard.
Marks 0-4
No recommendations presented or recommendations that are not achievable or not adequately related to the predisposing
factors.
Minimal literature used and literature is of a poor standard or is outdated.
The recommendations have been copied directly from the original reporting document.
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