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RCA REPORTON INCIDENT

RCA IIIVESTIGATION COMMITTEE:Chairman:Members: Dr. oo(Dr. oo(Dr. oo(SisterfiX

INCIDENT:The ncidentnvestigatedas:'On the 2sJanuqry 2009, at about 11,25pm, a male baby died in NICU ofSerdangHospilttl, due to CongenitqlPneumoniawith Sepsis.The baby wasdelivetedvia Emergercy LSCS on 24 January at 10,28am with Apgar Score 9/10 weighing3,4kg.Mother having gestationdiqbetic with diet contrcl and thk is sth pregnq cy'Her ultrasouwl shoved breechwith handpresentation'

SUMMARYOFROOTCAUSESOF INCIDENT:(a) Issueswith respecto managementndorganizationuthority,esponsibility'leadershipndcompetencY(b) Taskand echnologyactorsnvolving nadequaciesfknowledgeand ailureof complianceo prccedures.(c) Individual taff actors ertainingo lackofjob commitment,ompetencyndknowledge.(d) Team actors elating o lack of teamwork(e) Work/Cale nvironmentssues fpoorfacilitymaintenancend epalr'

SUMMARY OF ACTIONS:(a) Organization restructuring with emphasison leadership competencyand

hierarchy(b) QualityProcedure pdatingandclosersupervisionby Staffin charge(c) Upgradingof personnel ompetency.(d) Teamworkpractices o be strengthened.(e) Improvements to facility maintenance, epairs response and up$adingmedicaland T facilities.

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INTRODUCTION:On the 25 Jan 2009, a malebabypassed way ftom congenitalpneunoniawithsepsisn NICU of SerdangHospital. The motherG5P4having gestationald;abetesondiet controlledbrought n via EmergencyDepartmentor abdominalpain Shewaswas

not sure of her date and was then sent to ObstetricUnit just next to ED She wasexaminedby MO at the clinic andwas not sureofher finding She ordered or scanandshowed 8/52oblique ositionandhandpresentation.heconsultederspecialistn callandemergencyS-S wasca[ied out A babyboyapgar core /10weighing '4 kg wasdelivered-atb.28am.She asrefenedo paediatricMo on call afternoticed yanosedand tachypnoiec nd transferredo NICU. At 11.25pm the baby died afier 2"'resuscitation. heparentswere nfomed and heyaccepthe newsvery \tell'The case was discussedat the monthly mortality review and managementappointedn nvestigationeamon the29 January 009 o investigatehis incidentTheteamappointed oniistedof Dr.XXX, Dr'XXXi\, and SisterXXX given he scopeo

review'the ncidentand establishts root causes nd identifythe appropriatectionsrcquiredo rectify heweaknessesn order he ncidentwould not berepeated he eamtook approximatily neweeks o conductheir nvestigationn view that theyhave ocontinueheirday o daydutiesThemethodologymployedn the nvestigationncludeda reviewof the original ncident epod,site visits to the ward,and staff interviewstogether ith documentationhecks.

ANALYSISAND FINDINGS:An initial analysis f this incidentwas done o ascertaints SAC scofingto

determinehe ypeof RCA to beconducted.t wasdeteminedhat ts qctual mpnctottine jatient wai'maio\ $d the ikelihood ol recwtence was ike'l In view ofthis andwith cross referencing, t was detemined that thepotential risk to futurc pdtienls dndthe organizationwasexbeme,and terefoteafl/ -RCl was ndicated'A chonologyofeventsand esponsesf each ventwasdrawnup based pon heinvestigationsonducted.his s summarizedn the attachmentChronologyIncidentalMortuiry'. An analysiswas subsequently one utilizing the fishbone diagrammethodology ndsummarizedn the attachedishbonediagram

RECOMMENDATIONS:Theroot causes ndaction dentifiedwere as ollows:

(a) Root Cause: Management& organization: nadequatewith respect toresponsibility& leadership ompetency.'Action required: Restructr-rringf organizationchart wilh emphasisoncompetency hierarchY

authority,Ieadership

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Rationale: It was establishedhat therc was organizationandmanagementweaknessesthat required rectification. The successof any service is hrst dependenl on itsorganizitionalappropdateless, nd this deteminesthe effeclivenessof all otheraspectsof the organization.(b)Root Cause:Task& Technology actors:Lack ofknowledge & failure of complianceto procedues.,4ctiott Closersupervisionby staff in chargeRstionale: Implementationof programsandplans require hem being to be effective intherequiredmanner.nadequacyf suitable roceduresnd ack ofcomplianceo thesewill compromisehe effective onduct fthe program r plan.QualityProcureshat areplarured nd controlledare effective ools in assisting onsistentmplementationndactionsby staff.(c) RootCause: ndividual staff factors:Lack of commitment, nadequate ompetencyand lackofkrowledge

.4cli,rn.' ersonnelompetencyo beupgraded.mprove upervision'Rationale: The human factor is c tical in the successful implementation of anorganization'services. his requires hat the personnele appropriately.ained andqu-ulifi"d,d supervisedo ensue hatperformanceomplieswith the evel equired fthe ask.(d\RootCause: ea{r\actors: ackof teamwork..4clior.'Strengtheneamwork ractices.Rationdle:A, ch;inis as stong as tsweakestink Similarly,anorganizationependenton its human esoruceequirest to work effectively, ptimallyand efficiently this isdependentn good eamworkpractices.ailureo do socreatesn nefficientworkforcethat ncreasesnorganization'siabilitiesG\RootCause.Worldcareenvironment:ocumentationfcomplaintsacking' oo ongdowntime fequipmenthatarependingepaiN, oormonitoring follow-upactions',4ctior:Records fcomplaintso be kept n order.Supewisoro monitor hedowntime& clausemplementationo reduce elays.Ration e: A badworkmanblames is tools.Howevel,bad oolsmakegoodworkmenbad too. Havinga goodand well functioningacility is important or organization'sefficiencyandstaffproductivityAttachmentsf 'Resistanceto Change'and Monitoring& Communicating uccess'were utilized in the preparation of action plaruring and to assist in the subsequentevaluationf these ctions.RESIDUAL RISKS:The root causes, ctionsrequiredandtarget dates or evaluationale summarizedn theattacbment n 'Action Planning'.The failure to effectively implement heseactionswillpossibly esult n thq follori'r.g rcsidual sks:

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(a) Recurrencesfthis incident.(b) Failue of the organizationo comply o theguidelineor work process'ic) Result in customerdissatisfaction,customercomplaintsand probable egalliability consequent pon mpliedservicedelivery failure.

LEARNING POINTS:The appropdate implementation of an RCA investigation allowed theidentificationoi the root causesof an incidentthat was missed nitially by the originalIncidentReportassessmenty the deparhnentmanagement hich had concludedhat theproblemwis basedupon tlre infection contol havingnot been supervisedproperly andimproving IT services.Therewere howeverothermajor issues hat a proper approach

"outa t"t-p identif, failing which the iecurence of this incident was highly likely'Myopic aisessmentsmerely increasean organization's iabilities and leadto inadequateand nappropriate olution.ATTACHMENTS:

(a) CbronologYncidentAt Motuary(b) Fishbone nalYsis(c) Fishbone iagram(d) ActionPlanning(e) Resistanceo Change(0 Monitoring& CommunicatingSuccess(g) Copyof Original IncidentReportby Department oncemed(h) ExistingOrganizationChaltofDepafinent(i) Photogaphs