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FORM RCA 1
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
CONFIDENTIAL
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 Hayati
Wad 6
27.12.201
5
1750H
Wad 6
Wad 6
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
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
Sn Hanum( am shift)
Sn Hafizah(pm shift)
Sn Fazilah (on shift)
Wad 6
Sn Azila
Continue
monitor at right
hand and IV
Cloxacillin 1
gram QID
CONFIDENTIAL
FORM RCA 1
MANAGEMENT &
ORGANISATIONAL
FACTORS
TEAM FACTORS
TASK &
TECHNOLOGY
FACTORS
1. Lack of
communication
between staf
1. -
INCIDENT/ISSU
E
Thromboplebiti
s
PATIENT FACTORS
TASK &
TECHNOLOGY
FACTORS
1. -
WOR/CARE
ENVIROMENT
FACTORS
1. -
WORK/CARE
ENVIROMENT
FACTORS
1. -
* If not included in the London protocol, kindly place the contributing factor in the most suitable category provided.
CONFIDENTIAL
FORM RCA 1
EVENT 2
EVENT 3
EVENT 4
[EVENT]
[EVENT]
[EVENT]
[EVENT]
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
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 :
CONFIDENTIAL
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
CONFIDENTIAL
FORM RCA 1
Elimination
Applicable for any action taken where the hazard is substitute with a less hazardous
material/ procedure.
2
Substitution
Applicable for any action taken where technology/ engineering is used to reduce the
risk of incident.
3
Engineering control
Administrative control
5.
6.
Others
CONFIDENTIAL
FORM RCA 1
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 )
LEARNING POINTS
1. Establishing efective communication between staf and patient
2. Frequently observe venofix site
3. Documentation
REPORTED BY
DATE
: 08.01.2016