CONFIDENTIAL

FORM RCA 1

Root Cause Analysis

Incident Reporting & Learning System
CASE OF
: THROMBOPLEBITIS
DATE OF INCIDENT : ( 27 / 12 / 2015 )
INCIDENT CODE
: __________________
INTRODUCTION

98%
BRIEF description of Incident :
Name:Nur Sydatul Ain Bt Ahmad
Age:29
Race :malay
RN: 22491
Sex :Female
Reason for admit : TRO ECTOPIC PREGNANCY
Patient was admitted wad on 25.12.2015 at 1720H from yellow zone,patient on wheelchair
accompanied by ppk.General condition of patient stable venofix intact at rigt hand(dorsal vein
arch) on going IVD Normal Seline 1 pint.vital sign BP:113/64 pulse: 94 temperature : 39.2 0C
spo2 98% under room air.patient presented with fever x 3/7 and abdominal pain at left iliac fosa
x 3/7.case was seen by mo o&g at wad and planned for IVD 4 pint in 24H and blood
investigation Bhcg and NSI.patient was diagnose( 1)EARLY PREGNANCY TRO ECTOPIC
PREGNANCY( 2) TRO DENGUE FEVER.
26.12,2016 case seen by o&g specialist patient still having fever temp:37.6oC and URTI
symptom planned refer to medical.case seen by mo medical planned monitor FBC trend and
continue IVD as perdengue regime
27.12.2015 at 0750H venofix at right hand was off by sn hayati in view patient having pain and
redness. Ice pack was applied at pain site continueously shift by shift until pain resolved and
patient refuse to use ice pack.1900H patient develop fever again (T:38.80C)DHuda noted and
tapid sponging done.repeat temp 38.50C DR Dina noted and continue tapid sponging.
27.12.2015 case review back by mo medical and was diagnose (1)VIRAL FEVER WITH
TROMBOCYTOPENIA (2)THROMBOPLEBITIS (3)UNLIKELY DENGUE FEVE.
Planned suggest for iv cloxacillin 1 gram QID in view of thrombophlebitis.
Case seen back by mo o&g at night round and was started iv cloxacillin 1 gram QID.
Team assigned for investigation :

ANALYSIS &FINDINGS :
1

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FORM RCA 1

Sequence of event
Date

Time
(24 h)

Location

25.12.201
5

1615H

A&E

1720H

Wad 6

2100H

0700H

Wad 6

25.12.201
5
25.12.201
5
26.12.101
5

Event description
Venofix inserted on the
patient at the right hand
(DVA)
Patient on going IVD
normal seline from A&E
Patient still on going
IVD 4 pint normal
seline

Sn Ana Huwaina

IVD rinnung
well no
thromboplebtris

Sn Fazilah (am shift)

Sn Azila(pm shift)
Sn Ana (on shift)

Sn Hayati

Wad 6

Patient still on IVD

normal seline 4 pint in
24H

27.12.201
5

1750H

Wad 6

Review on venofix site

during observation
noted redness and pain

Wad 6

New venofix was

inserted at left dorsal
vein arch and IVD
normal seline 52ml/H
continued

27.12.201
5

0000H

28.12.201
5
29.12.201
5

0700H
0700H

29.12.201
5

0900H

DR Roma
IVD running
well

0700
0700H

1130H

Comments

Sn Hafizah

26.12.201
5
27.12.201
5

27.12.201
5

Key person
involved&
designation

IVD running
well no
complain of
pain or redness
at venofix site
Venofix remove
and ice pack
was applied at
pain site

Dr Dina

Ice pack still

continue
applied at right
hand

Wad 6

IV Cloxacillin 1 gram
QID was started given
at left dorsal vein arch
venofix

Sn Rashdah
Sn Vinotini

IV Cloxacillin
running well no
complain of
pain fron
patient
Ice pack still
applied to the
right hand

Wad 6

Vervalise from patient

pain reduce

Sn Hanum( am shift)
Sn Hafizah(pm shift)
Sn Fazilah (on shift)

Ice pack still

applied to the
right hand
patietn

Wad 6

Vervalise from patient

no more pain at right
hand

Sn Azila

Continue
monitor at right
hand and IV
Cloxacillin 1
gram QID

CONFIDENTIAL

FORM RCA 1

FISH BONE DIAGRAM (REFER TO LONDON PROTOCOL FOR CATEGORISATION)

MANAGEMENT &
ORGANISATIONAL
FACTORS

TEAM FACTORS

TASK &
TECHNOLOGY
FACTORS

1. Lack of
communication
between staf

Not enough staf

1. -

INCIDENT/ISSU
E
Thromboplebiti
s

PATIENT FACTORS
TASK &
TECHNOLOGY
FACTORS
1. -

WOR/CARE
ENVIROMENT
FACTORS
1. -

WORK/CARE
ENVIROMENT
FACTORS
1. -

1. Patient always ask to

stopper the IVD once
going to toilet
2. Sometime patient bring
the IVD to the toilet
without clamp the
tubing
3. Patient fear to insert

* If not included in the London protocol, kindly place the contributing factor in the most suitable category provided.

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FORM RCA 1

EVENT CAUSAL FACTOR CHART (OPTION 1)

EVENT 1

EVENT 2

EVENT 3

EVENT 4

[EVENT]

[EVENT]

[EVENT]

[EVENT]

[DATE & TIME]

[DATE & TIME]

[DATE & TIME]

[DATE & TIME]

CAUSED BY

CAUSED BY

CAUSED BY

CAUSED BY

- [ EXPLAINATION ]

- [ EXPLAINATION ]

- [ EXPLAINATION ]

- [ EXPLAINATION ]

CAUSED BY

CAUSED BY

CAUSED BY

CAUSED BY

- [ EXPLAINATION ]

- [ EXPLAINATION ]

- [ EXPLAINATION ]

- [ EXPLAINATION ]

CAUSED BY

CAUSED BY

CAUSED BY

CAUSED BY

- [ EXPLAINATION ]

- [ EXPLAINATION ]

- [ EXPLAINATION ]

- [ EXPLAINATION ]

CONTINUEON
THE NEXT PAGE /
FINAL INCIDENT
OR ISSUE

CONFIDENTIAL

FORM RCA 1

5 WHY METHOD( OPTION 2)

(Identify problem / issue and ask why for at least 5 times to gain the root
cause(s))
PROBLEM / ISSUES

QUESTION :WHY.

ANSWER :
1. CANNOT GET COOPERATIO FROM PATIENT

QUESTION :WHY ..

ANSWER :
1. LACK OF COMMUNICATION BETWEEN TEAM(DOCTOR,NURSE)

QUESTION :WHY ..

ANSWER :
1. SHOULD BE MONITORED MORE FREQUENTLY

QUESTION :WHY ..

ANSWER :
1. NOT ENOUGH STAFF

QUESTION :WHY ..

ANSWER :

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FORM RCA 1

Recommendations
1. Root cause(s) identified.
Use the following coding :
Code
1
2
3
4
5
6
7
8

Factor
Patient Factor
Task and technology factor
Staff factor
Team factor
Work & care environment factor
Management and organisation factor
External factor
Other ( Unspecified )

CATEGORY OF
FACTOR

ROOT CAUSE

Patient not complain of pain because patient fear to insert new venofix

Lack of communication between team(doctor,nurse)

Not enough staf

CONFIDENTIAL

FORM RCA 1

2. ACTION PLAN/ RISK REDUCTION STRATEGIES CATEGORY

CODE

ACTION PLAN CATEGORY

EXPLANATION & EXAMPLES OF ACTION PLAN

Applicable for any action taken where the hazard is removed to prevent the
reoccurrence of incident.

Elimination

Removing unnecessary step(s) in procedure or S.O.P

Removing faulty device / equipment
Removal of hazardous material

Applicable for any action taken where the hazard is substitute with a less hazardous
material/ procedure.
2

Substitution

Replacing hazardous equipment with safer equipment.

Applicable for any action taken where technology/ engineering is used to reduce the
risk of incident.
3

Engineering control

Application of IT system for prescription of medicine to prevent medication

error
Usage of central alarm system for patient on ventilator

Usage of regulations, policies or S.O.P(s) to reduce the risk of incident

Administrative control

5.

Personal protective equipment

6.

Others

Implementation of checklist & safe work practices

Improvement of staf rotation / shift
Develop new policy, guideline or S.O.P
Education / CME / CNE
Human resource
Preventive maintained

Usage of protective equipment

Not included in any categories specified

CONFIDENTIAL

FORM RCA 1

Action plan table

No
.

Root Cause

Lack of
implementation of
checklist and safe
work practice

Action
Code.

Action Plan

Implementation of checklist
and safe work practice

Person responsible

Doctor/nurse

Due
date

Review
Date

Outcome
Measures

Completio
n Date

27.12.20
15

28.12.20
15

No thromboplebitis

30.12.2015

CONFIDENTIAL

FORM RCA 1

RESIDUAL RISK
( Outline residual risk that will exist if risk reduction strategies/ corrective
actions are not taken )

Increase number of thrombophlebitis case

LEARNING POINTS
1. Establishing efective communication between staf and patient
2. Frequently observe venofix site
3. Documentation

REPORTED BY

: JT DAYANG ZAHUNA BINTI AB RAZAK

CHECKED & CORRECTED BY : KJ RADIYAH BINTI ABU BAKAR

DATE

: 08.01.2016