PHCM9748 Clinical Governance And Risk Management : Essay Fountain


1.Describe the process you would use for selection of your Root Cause Analysis team.  Outline who you would include; who you would exclude; and your rationale for these decisions .

2.Describe one or more incident investigation techniques that you would utilise to investigate this event. Summarise the key strengths and limitations of this technique.

3.Provide a concise narrative chronological account of what happened to this patient

4.Insert a process diagram demonstrating what happened to this patient

5.Populate the Root Causes and Contributing Factors

6.Populate RCA team recommendations


1. Selecting the RCA team is a process that requires due diligence. The process must be carried out keenly while considering the people to include in the team and the people to leave out. When assembling the RCA team, it is critical to consult the major stakeholders who are involved in the issue being investigated. In this case, the team will be tasked with the responsibility of investigating the root cause of Rory`s death. The paper investigates what is the main risk which contributed to the death of the 12 year old boy. In the RCA team, the representatives of the health department will be included in the team. The representative will represent the Government so that they can offer the view of the government in regard to solving such future casse (Kelly,Blake & Plunkett, 2016).  Dr Susan Levitzky will also be selected to the RCA team. She will be of great help in providing information on what transpired when she assessed Rory for the first time. Dr. Susan will also be of great assistance to the team because she holds key information on the tests she conducted on Rory before diagnosing him stomach unrest. This is despite the insistence by the patient and his mother that despite the vomiting, he experienced a lot of pain on the leg. The NYU physician who attended on Rory will also be included in the RCA team. The physician will be expected to bring to light information on how they arrived at the diagnosis that Rory was sick in the stomach and was dehydrated despite there being no tests which confirm this (Liu et al., 2014). The NYU physician will also be involved so as to explain why they did not consider sepsis despite the sepsis screening tool indicating that Rory had two symptoms out of the possible eight that a person with sepsis could have.In order to get to the root cause of Rory`s death,  it is also critical to involve the management of NYU as part of the TCA team. Involving the management will help the team to get information on the occurrences of that particular day. Additionally, the management of the hospital will offer their suggestions and recommendations on steps that should be taken in order to avoid such occurrence in future. According to Peerally et al.,(2017) , a safety officer who has experience in safety in healthcare should included in the RCA team.The officer plays a crucial role in providing professional guidance and opinion regarding safety practices in an healthcare setting (Taylor et al., 2016). The local health and safety committee will also be involved in this investigation. Furthermore, the investigation team will involve representatives of the doctors union. The doctors union is critical in this case because if they are involved in the RCA of this case, they will provide appropriate recommendations which will guide their members to improve healthcare safety in case they find themselves in similar circumstances in future (Fleischmann et al., 2016) The RCA team will also comprise of an independent expert in matters relating to healthcare safety. Their role in the team will be analyzing the statements provided by both the hospital and Rory`s parent to establish the truth about what transpired in this case. The police will not be involved because this is not a criminal investigation but an investigation aimed at establishing the root cause of the problem and hence identifying measures that should be taken to avoid such future occurrences.


2. This study uses the systems of analysis  technique and the Swiss model . The system of  analysis technique  focuses on problems in the systems which could have caused a particular undesired situation (Carayon et al., 2014). This technique focuses more on organizational factors that could have led to the problem without focusing much on the individual who made the mistake. More often, mistakes by human beings lead to huge disasters such as air crashes, road accident and sometimes surgeries go wrong causing death of human beings. People more be quick to place blame on a particular person or organizations and without understanding the complex factors and activities that could have led to the problem. The system analysis technique helps in investigating and understanding the root causes of the problem without making unbiased conclusions (Kaukonen et al., 2014),. The first step in this technique is identification of a point where a person/group of people deviated from standards of good practice. The systems problem technique enables the investigating team to identify the series of events and activities leading up to the problem and investigates how the work environment and process in an organization could have influenced the occurrence of the problem (Strauch, 2017). The technique involves identification of the care management problems that may exist in the hospital. Problems of care management can be defined as actions or omissions by healthcare workers which may lead to occurrence of undesired situation ( Daviaud et al., 2015). Such actions or omissions may include use of wrong , errors in judgement and rare departures from the standards and procedures of practice which may be intentional of unintentional. When assessing care management problems, it is important to consider two critical concepts. The first concept is considering whether the care offered deviated from the standards of safe practice (Reinhart et al., 2017). The second aspect is to evaluate if the deviation had a direct impact on the adverse outcome of the patient. In the case of Rory, deviation from safe practice had a direct impact on the patient because it resulted to the death of the patient. After identifying the problems associated with care management, the team records the factors related to the patient that could have led to the occurrence of the event.This steps involves identifying issues such as blood pressure of the patient, heartbeat as well as failure to adhere to the treatment instructions. The team will collect information relating to Rory case by conducting interviews with various parties involved in the treatment  of Rory either directly or indirectly. Additionally,structured questionnaires will also be used in the investigation.


The systems analysis investigation technique has many strengths and a variety of weakness. One of the strengths of the investigation technique used is that it ensures a comprehensive investigation on an incident are carried out and official reports are compiled (Keers,  Williams,  Cooke & Ashcroft, 2013). Unlike many other investigation techniques, the systems analysis technique carries an in-depth investigation which identifies many factors which contribute to the situation. The other strength of the method is that it focuses more on processes within an organization and not an individual (Bowie,Skinner & de Wet, 2013). Focusing on processes gives a big picture of what could have contributed to the death of Rory. This can therefore helps in putting measures in place to improve patient care and treatment so as to avoid death as a result of similar circumstances. The technique also promotes a culture of openness in heathcare since it does not apportion blame to one person (Macrae & Vincent, 2014). This therefore encourages staff to be more honest because they feel less threatened.

The weaknesses of the technique used in the investigation is that it takes a long time to complete (Stevenson et al., 2014). The system problem technique involves a lot of procedures and hence it may take a longtime to establish cause of the problem. The other weakness of this technique is that it focuses more on future and does not hold anyone accountable for what has happened (Khakzad,  Khan and Amyotte,  2013). This therefore means that this technique cannot be used to conduct a legal investigation.

The Swiss cheese model is also very critical in investigating cases of medical errors. This model is close to system analysis model since it also investigates mishaps in the procedures and processes which could have resulted to an error (Underwood and Waterson,  2014). The model states that various hazards that exist in the environment are prevented from causing harm to a human being by the barriers that exist in the cheese system. Harm therefore occurs when the holes open at the same time.  The weakness of this model is that it cannot be helpful in identifying problems until all the holes are aligned and hence meaning that serious harm has to happen for it to be applied.

3. Rory who is a 12 year old boy had cut his arm while diving for a basketball at the school gym on march 28. Rory did not receive any medical attention on the same day because he thought it was a small wound that did not need much care.However, the wound was bandaged and he got first aid from the athletic director and continued with his activities as usual (Krumholz, 2014). When he got home, he reported the incidence to his parents that he had fell in the gym and then he did the assignment and went to bed. Some few minutes after midnight on the same night, his mother Ms. Staunton heard Rory retching in the bathroom despite there being no huge amount of vomit on the floor. His mother narrates that Rory was complaining about pain on his leg and he did not complain about experiencing any pain in the stomach. On the morning of  March 29, 2012 Rory`s mother took his temperature reading and she noticed that he had a temperature of 104 degrees (McPherson et al., 2013). He was also looking weak and frail. At that instance, the mother  decided to call the family pediatrician named Dr. Susan Levitzky.Rory`s mother managed to take her to the hospital to see Dr. Susan on the same evening. When they arrived at Dr. Susan`s office, Rory was so weak  that he could not stand by himself. He also vomited in the waiting room and also while Dr. Susan was examining him. Dr. Susan therefore decided to test for streptococcus bacteria using the swab test. The swab test is a rapid but non-definitive test for streptococcus.

During examination of the patient, Ms. Staunton tried to explain to the doctor that Rory was mainly complaining about his leg and not the stomach where the Doctors focus was. The doctor dismissed their suggestions and insisted that the pain on the leg could be due to the fall she experienced in the gym. Additionally, Dr. Susan had been made aware of blotching on the boys skin which could mean that he had low blood pressure. Irrespective of this, the doctor did not bother to examine him further.On Friday night, Rory experiences the bout of diarrhea that has been predicted.


Dr Susan directed the patient and the parent to visit NYU hospital for re-hydration. The doctors at NYU langone also believed that Rory was suffering from stomach discomfort and dehydration. Some tests were conducted but the doctor had already decided to release the patient even before getting the results. When they went home, Rory`s condition became worse and his nose and other parts of the body started turning blue. He was rushed back to NYU Langone hospital and was admitted to the emergency department where he was put on ventilator. On Sunday, he experienced two cardiac arrests and was resuscitated. The third attempt however failed and Rory passed on that Sunday afternoon.



Process diagram

5. Populate the table below withRoot Causes and Contributing Factors 

Item No. Description of root cause/contributory factor Category (as described in the Checklist Flip Chart for Root Cause Analysis Teams)

Communication Knowledge, skills and competence Work environment/ scheduling Patient factors Equipment Policies/ procedures Safety mechanisms

1 (Root Cause)Delay in standard protocol of diagnosing sepsis There were no policies and procedures to guide doctors in diagnosing patients who have sepsis. It therefore was very difficult for the doctors treating Rory to identify the disease that Rory was ailing from.

2 Lack of necessary equipment for testing

From the analysis, it is clear that Dr Susan used a swab test which is defined as a non-definitive detector of streptococcus bacteria. The test showed that the test was negative despite Rory being infected with the bacteria.

3 The test results were not reviewed with the clinician familiar with the case of the patient

The blood tests which the doctor ordered be done were not reviewed by the same doctor. The results were offered to another doctor who ended up discharging Rory without considering how the tests could influence the treatment of the patient. This therefore contributed to increased risk to the patient .

4 Poor communication between physician and the patient`s guardian

Dr. Susan did not tell the boys mother that she noticed that there were some vital signs which were not okay with the child. The doctor only recommended that the boy should be taken to NYU hospital for re-hydration. The physicians at NYU hospital also did not provide the lab results to parents and did not notify him how sick her son was and hence contributing to this problem


Lack of communication between Physicians Dr. Susan did not communicate to the LYU Langone regarding any tests she had done on the patient or observations she had noted about the patient. This contributed to the problem since with better communication, doctors at NYU Langone could have conducted further examination of the patient and the situation could have been avoided

6 Discharging the patient before the results of the tests were out

The doctor who ordered that Rory should be discharged even before getting the results showed incompetence. Even after getting the results and noticing that three signs of the patient could indicate sepsis, the doctor still allowed the patient to go home without considering the results of the tests. If this was considered, the outcome could have been different


The patient was not examined for a sufficient period of time   Despite the parents of the kid explaining the situation to the doctor and having been referred with a serious case. The doctor at NYU did not take the case serious and he discharged the patient without observing and examining him properly.the safety of the patient would have been assured if the doctor had put the safety and well-being of the patient first.


6. Populate the table below with RCA team recommendations

Causation statement item no. Recommendations

Description of actions to be taken Risk classification

Accept Outcome measures Completion date

e.g. Within 3 months

1 New policies and procedures should be put in place to guide doctors in diagnosing sepsis. A checklist can be made of considerations that doctors should observe when treating a patient who has symptoms related to sepsis (Rafter et al., 2014)

Eliminate Evaluating the effectiveness of the policies by examining whether deaths as a result of sepsis have decreased 6 year

2 Equipment that do not show definitive results should not be used at the hospital

Control Observing the testing equipment being used in hospitals 1 year

3 Improvement of work scheduling to ensure that a physician who is familiar with the case of a particular patient deals with it from beginning to the end (Rhee et al., 2017) Control Re-scheduling of work in hospitals and specialization 3 months

4 Improve communication with the patient

Eliminate Assessing whether all tests or information relating to the patient has been brought to their attention 3 months

5 Physicians and hospitals should follow proper procedures when handing over patients to other doctors or referring a patient to another hospital. This ensures that all the critical and relevant information relating to the patient is communicated and hence improving safety and patient outcomes

Eliminate Carrying out regular audits to determine whether clinical handovers are carried out according to the laid down procedures. 1 year

6 Proper training of healthcare staff should be provided to equip the doctors with the necessary knowledge and skills on diagnosis and treatment of sepsis.

Accept Assessing doctors and nurses to determine whether they are practising in accordance with the skills and knowledge provided 6 months

7 Involvement of the patient in care. If the doctors had listened to Rory`s narrative and that of his mother. They could have realized that the patient did not experience any stomach discomfort and could have tried a different diagnosis Accept Level of involvement of patient in care 1 Month.



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Underwood, P. and Waterson, P., 2014. Systems thinking, the Swiss Cheese Model and accident analysis: a comparative systemic analysis of the Grayrigg train derailment using the ATSB, AcciMap and STAMP models. Accident Analysis & Prevention, 68, pp.75-94.

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