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Cause analysis a formal investigative process that involve the input of a multidisciplinary team. It helps in ascertaining the root etiology of clinical incident thereby providing a basis for making in the system of care. It is designed to enable prevention of recurrence of the incident. A cause analysis focuses more on the system of care rather than individuals. It deters the likelihood of identifying the involved individuals in the clinical incident. It requires appropriate and efficient communication and documentation system. It is applicable in situations that involve an avoidable incident that had the potential to harm the patient in one way, or another (Secker-Walker & Taylor-Adams, 2001).

There are several tools that need to be used to conduct cause analysis. Fishbone technique is one of the tools used in conducting cause analysis. It is also known as Ishikawa. It is very crucial in eliciting the cause of clinical incident in that it help focus on the specific aspects of causes. It helps in streamlining of the line of enquiry and provide more precision in analysis of causes of problems in clinical setting (Brown, Frost, Ko, & Woosley, 2006).

It involves a nine step procedure. Each step tackle one contributory factor. These factors can be further classified into subgroups. The first step involves defining the events that require investigation. The second step entails selection of a multidisciplinary team. The next third step involves collection of key data from documents and individuals involved in the incident (Brown et al., 2006).

The fourth step collates information collected from all possible sources in order to be user-friendly. The fifth step entails use of involved individuals in identification contributory events while the sixth step uses the fishbone template to investigate and identify contributory factors. The final steps involve the development of desired recommendation, documentation and publishing (Brown et al., 2006).

Fishbone root cause analysis template

Root Cause AnalysisRoot Cause Analysis 1


Root Cause Analysis 2Root Cause Analysis 3Root Cause Analysis 4

Root Cause Analysis 5Non-operational clinic days

Root Cause Analysis 6Clinical staff Negligence difficulty in booking an failure of the answering

Egocentrism appointment machine

Non-compliance difficulty in obtaining inpatient inadequate staff

and outpatient psychiatric care Training

Root Cause Analysis 7Root Cause Analysis 8Root Cause Analysis 9Root Cause Analysis 10Root Cause Analysis 11Root Cause Analysis 12Root Cause Analysis 13Root Cause Analysis 14


Septic shock



Personal interests difficulty in the

Access of electronic health record

Lack of hospital emergency inability to access care due to long distance to the facility

Transport for the sick

Lack of effective

Clinical supervision

Potential intervention strategies

Potential physical human strategies include involved patient first strategies, staff development strategy, communication strategy, and staff support strategy. In addition, the potential physical strategies include equipment and system maintenance strategy, emergency patient transport strategy, establishment of a multidisciplinary team, and audit or physical inspection. The potential organization strategies include scheduling, appointment, drug dispensation and sentinel event reporting strategy.

Root Cause Analysis 15Root Cause Analysis 16Root Cause Analysis 17


Root Cause Analysis 18Root Cause Analysis 19Root Cause Analysis 20

Clinical honesty staff development strategy maintenance strategy

Therapy compliance Sentinel event reporting

Counselling staff scheduling strategy

Multidisciplinary teamwork Decentralization of follow up care

To the community

Root Cause Analysis 21Root Cause Analysis 22Root Cause Analysis 23Root Cause Analysis 24Root Cause Analysis 25Root Cause Analysis 26Root Cause Analysis 27


Septic shock



Patient first strategy

Communication strategy

Root Cause Analysis 28Clinical record audit

Patient emergency transport Road network maintenance

Evidence based intervention

Patient first strategy

According to Nicolini, Waring, & Mengis, (2011) and Iedema, Jorm, Braithwaite, Travaglia, & Lum, (2006) patient safety should be prioritized in occurrence of any clinical incidence. The main aim should be to ensure safety of the subject of which the consequences of the incidence has a higher probability to affect him. The clinicians should take all necessary steps to ensure that they treat and support the affected patient promptly as soon as the clinical error is ascertained. As argued by Nicolini et al., (2011) prompt response to the perceived or actual clinical incidence guarantees good outcomes. It calls for intervention measures that act in favor of the patient side and always advocate for the patient well-being and human dignity of the patient. The process of patient safety first should commence with detailed and accurate documentation of the incidence in the patient record. It ensures that all the staff who will attend to the patient in the future will be fully aware of what went on previously.

In connection with Jane’s case, this aspect of patient safety was not clearly adhered to. For instance, there are so many instances of undocumented clinical proceedings that could not be traced by the reporting staff on duty. Nevertheless, the laboratory tests that were ordered for were not timely checked for their findings. It is then crucial to strengthen the patient safety measures to ensure all the medical and nursing staff act always with consideration of the patient safety.

Secondly, the staff development strategy is of the next priority. In connection with the incidence of a medical director’s inability to check for the laboratory results at the electronic health record signify, that majority of the staff are not at par with the technologic advancement. It becomes of priority in that if the medical doctor knew how to operate the patient would not have been discharged. Saxena, Seebacher, Bernhardt, & Höllwarth, (2007) postulate that effective and continuous staff development is a vital key towards ensuring effective prevention of clinical errors and incidences. They further argue that many clinical errors occur because of lack of technical skills over new advancements at the workplace. The era of evidence based practice has tremendously resulted in changes in the health care system that calls for staff training.

It is, therefore, crucial for the staff development unit to devise new programs that provide basic training to the staff. As per the case of Jane, new and old staff should be trained on computer skills and specific program operation skills to ensure efficiency and effectiveness when exercising their clinical duties. The strategy should advance for immediate training soon before or after adopting a new technology to the health care. Similarly, Desai & Johnson, (2013) advances that allowing free access to the clinical record databases by all designated staff help reduce the probability of omission errors in reporting of the patient record.

Clinical supervision strategy

According to Grayson, (2011), Davis & Burke, (2012), Knutton & Pover, (2004) clinical supervision is a vital strategy in alleviating incidence of negligence at workplace. It calls for close supervision to ensure that those errors that are either committed willingly or unwillingly are prevented and addressed before causing significant harm to the patient and facility, as well. Nicolini, D., Waring, J., & Mengis, J. (2011) calls for clinical honesty during patient supervision process. They advance that honesty enables collection of accurate occurrences during the incidence and promote effective intervention measures to curtail the problem. Many at times, clinicians fail to carry out their duties diligently, thus, causing harm to the patient. As witnessed in Jane’s case, several medical staff acted negligently but failed to act with honesty over the case. Majority were overwhelmed by egocentrism and failed to give accurate information about the patient during clinical discussion. It is, therefore, crucial to design and implement clinical supervision strategy in order to curb the rising clinical incidences.

Scheduling and patient- clinician appointment

Majority of Jane’s attending clinicians purport that the patient delay at the hospital is because of the inability to book an appointment with a psychiatrist. In addition, Jane failed to receive plaquenil because the eye examination history was unavailable. Moreover, the ophthalmologist was not available during weekends thus the patient had to wait till following Monday before commencing the vital SLE drug. Many researchers argue that many clinical incidences could be prevented with effect of appropriate scheduling. Hu et al., (2010) reports that the majority of documented clinical incidences occurs over the weekends when the few staff is scheduled to be on duty. It is true in that majority of specialized clinics are non-operational over the weekend. It makes it hard for acute patients to acquired desired medical care during the weekends similar those attended during the working days. It creates unfairness in a situation beyond the control of the patient. They, therefore, recommended scheduling of staff on call who mans specialized clinics at the facility to ensure smooth continuity of care and patient safety, as well.

Communication strategy

Current clinical practice require effective breakdown of complex consultation phenomenon to simple and specific basic components. In connection to Jane’s case, the medical supervisor of medical interns fails to report his mistake of not writing prescription order on the patient records to his junior staff. This was because he has been so harsh to the junior staff. His junior staff, therefore, perceived him as experienced and always accurate in his clinical duties. In addition, one junior staff noted the chief complaints of the patient soon before discharge. Given the complexity of senior and junior staff complexity, he was not able to air his clinical views effectively.

Nicolini et al., (2011) recommends that communication process between carers, staff and the patients should be made clear and sensitive. The pattern of the communication should be in line with the strategic goals of the health care facility.

Maintenance strategy

The other strategy that can be employed in management of cause analysis in health care is machine and equipment maintenance. According to Scavarda, Bouzdine-Chameeva, Goldstein, Hays, & Hill, (2006) approximately thirty to forty percent of the clinical operations solely depends on machines and equipment. The integrity of these equipment and machines is the key determinant of the patient clinical outcomes. Even though the case of Jane was not directly linked with equipment failure, the failure of answering played a role in the clinical confusion over the case of the patient. According to Hu et al., (2010) effective maintenance of the hospital equipment is crucial in ensuring quality patient care. Establishment of operational maintenance department is important. The unit should then be conjured with the mandate to regularly check on the hospital machines and equipment for repairs and replacements.


Cause analysis is an important strategy that enables detailed scrutiny of the major cause of clinical incidences at health care setting. It is an important approach that ensures that the clinical incidences are discovered and managed as soon as possible. It also aims at preventing the recurrence of the clinical incidences in the future. It is a well devised approach with several tools that are be used to effect the investigation (Evans et al., 2006).

In most cases, the approach requires the attention of a multidisciplinary team that ensures that the detailed report over the clinical case is ascertained. The adopted cause analysis tool is fishbone technique. It covers investigation of six aspects of health care. These aspects include people, machines, environment, materials, supervision, and process of care. It involves the devise of fishbone-like template that give a glimpse of and possible intervention measures.

The main cause of the clinical incidences is divided into three on the basis of their nature. The first category is physical human cause that entirely reflected on human aspects that played a role in clinical case. The second category involve organizational causes that involve procedures, resources, and policies that significantly caused the occurrence of the clinical incidence. The last category is physical factors that include system and equipment problems.

The major intervention measures discussed was derived from research evidence that supported the effectiveness of these measures. Some of the championed measures include patient safety first, communication skills, clinical supervision, maintenance and staff scheduling strategies. The effectiveness of the discussed strategies is supported by clinical evidences that have proved to help curtail the clinical case in health care (Kemppainen, 2000).


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