Root Cause Analysis (RCA) Data

System Factors in Clinical Incidents

A RCA is required to investigate every clinical SAC/Harm Score1 and some SAC/Harm Score2-4 incidents in the NSW public health system. The RCA method is used to identify how organisational systems can cause or contribute to clinical incidents. The RCA report findings and state-wide aggregated analysis inform system improvements aimed at preventing similar incidents from occurring in the future. Examples of these include the development of programs, reports, and quality tools including Between the Flags, Sepsis Kills, Patient Safety Watches, and Safety Alert Broadcasts.

The CEC reviews all clinical RCA reports through four RCA review committees: Clinical Management, Maternal and Perinatal, Mental Health/Drug & Alcohol, and Child and Young Person. The RCA Review committees classify each RCA report using a standard classification system (referred to a taxonomy in this report) which is revised as new issues and clinical practice changes are identified.

System factors is the broad term given to the environment, conditions, and processes that were present at the time of an incident and may have contributed to the incident.

During the reporting period of January – June 2020, the top system factor identified by the Clinical Management, Maternal and Perinatal, and Mental Health/Drug & Alcohol Review Committees related to Care Planning. The top system factor related to Child and Young Person RCAs was related to Observations and Monitoring.

The system factor Care Planning relates to incidents where there may have been gaps or failures to work together to plan care for patients receiving care from more than one team. This includes care continuity and care co-ordination within a facility or between health care facilities, including private providers, inpatient, and community-based services. Care Planning also covers incidents which happen when a patient's risk factors (for example additional illnesses or injuries, falls risk, or the capacity of their carers to manage ongoing care) have not been properly assessed or managed.