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The research sample (48 RCAs) comprised 13 medical SAC 1 clinical events, 17 surgical SAC 1 clinical events, 5 obstetric and gynaecological SAC 1 clinical events and 12 mental health SAC 1 clinical events. As noted, the RCA is exempt in the event of

community suicide. However, the sample contained 8 RCAs involving community suicides and one RCA was an inpatient mental health death. With the exception of one mental health RCA, no root causes were identified in the mental health RCAs. Lessons learned were identified in 10 of the 12 mental health RCAs. One RCA was excluded because it contained a HEAPS analysis and not RCA. Figure 5.1 represents the proportion of RCAs by healthcare divisions.

Figure 5.1. RCAs by divisions of care.

RCA sections

The structure of the RCA was explained in Chapter 2. According to the Health and Other Legislation Amendment Act (2007), it is not compulsory for an RCA report to contain all three sections: the report and the chain of events diagrams 1 and 2. The Health and Other

Mental Health 25%

Medicine 28%

Surgical 36%

O&G 11%

RCA's 2009-2011

Legislation Amendment Act (2007) asserts that the RCA team must prepare a report although the COE component is optional and is represented in the data. The report template comprises three parts: a description of the event; causal statements; and recommendations to change or improve policy, procedure or practice relating to the provision of health service (Health and Other Legislation Amendment Act, 2007, s5). The composition of the chain of events diagram(s) is at the discretion of the RCA team as the Act asserts that “the RCA team may prepare the chain of events diagram . . . ” (Health and Other Legislation Amendment Act, 2007, s5)

All sampled RCAs (100%) contained a descriptive narrative report (N = 47). Of the sample, 80% (n = 39) completed the chain of event document part 1. Of these, 31% (n = 22) identified barriers where latent causality appears and corrective actions may be considered.

Nine, or 18%, did not complete the chain of events document part 1. Of those without the chain of events document part 1, most identified lessons learned and 1 RCA made

recommendations. Nineteen or 40% developed root causes; 48% (n = 19) provided solutions in the form of recommendations and 79% (n = 37) provided solutions in the form of lessons learned.

As noted, the approach to completion of an RCA is legislatively supported (Health and Other Legislation Amendment Act, 2007). Figure 5.2 depicts an overview of these characteristics.

Figure 5.2. Percentage of RCAs with completed chain of event document, part 1.

Chain of Events 81%

No chain of events 17%

Excluded 2%

Chain of events document: Part 1

Of the RCAs that completed chain of events documents part 1, 43% (n = 19) completed chain of events document part 2 and identified root causes. Of the sample, 57%

(n = 19) of the RCAs did not complete a chain of events document, part 2 and no root causes were identified. Figure 5.3 represents the proportion of RCAs that completed a chain of events document part 2.

Figure 5.3. Percentage of RCAs with completed chain of events documents, part 2.

5.2 THE ENVIRONMENT

The category of the environment refers to the social and political dimensions of healthcare. This includes regulatory frameworks, legislation, associated networks and inter-organisational agencies that inform the perspective of healthcare (Vaughan, 1999, p. 275).

Twenty-nine RCA excerpts were sorted into this category and five groups of text emerged.

There was no text that referred to external governances that bureaucratically and economically inform healthcare such as legal or political influences. One RCA recommended that relocation of services would improve the timeliness of healthcare.

The text sorted into this category used language that was associated with the culture of healthcare. For excerpts of text and the theoretical sorting processes in this category refer to Appendices D for full data frames. From 5 RCAs 8 excerpts of text were sourced that applied cultural inferences to describe issues of non-compliance or lack of teamwork.

Examples are “staff do not routinely escalate concerns to after hour’s manager or Root causes

40%

No root cause 58%

Excluded 2%

Chain of events: Part 2

consultant” (RCA #20), “Differences between divisional practices” (RCA #24). Of these, two RCAs used exclusive cultural inferences: “A culture of not using the system” (RCA

#16), “A culture that pressure areas are a nurses domain” (RCA #6), “Culture for nurses to re-position (RCA #6)” and “Culture of non-compliance” (RCA #12). The analysis also extracted groups of words that acknowledged gaps in healthcare infrastructure such as

“external programs not linked to inpatient services” (RCA #38) and “managed by part-time clinicians” (RCA #33). The text in the RCAs also identified infrastructure deficits, 30%

(n = 6) such as a lack of inter-organisational agencies to support patients following

discharge. Examples include: “no off-site services” (RCA #47), “sent home for follow-up”,

“external programs not linked to inpatient services” (RCA #37), “lack of client booking and allocation system” (RCA #45) and “Stress test not available” (RCA # 25).

From the text in this category, 17% (n = 4) of excerpts acknowledged Queensland Health’s vast geographical catchment as a source of concern. Two RCAs identified the complexities of patient care in outback Queensland where a lack of remote services was complicated by transportation difficulties. Examples include “Lack of roads and resources”,

“Pilot could not land in terrain”, “Remote geographical location of injury” and “Trauma in isolated region” (all from RCA #3). Following the issue of transport, the RCA was

concerned with delays related to remote areas of Queensland especially in relation to getting patients from rural areas to tertiary services in an efficient manner. Examples include

“Transfer delay” (RCAs #3, #17) and “Length of time for retrieval” (RCA #3). Delays in treatment were attributed to location, development of sepsis and complex treatment regimes.

Further, the RCAs identified considerable time was spent communicating between services.

This combined with emergency care in rural health services was described as complex.

Patient care was compromised due to isolation in rural parts of Queensland. The distance between healthcare services was not only limited by the terrain but the scope of the nearest service and the availability of transport. The proportion of text is represented in Figure 5.4.

Figure 5.4. Environment category – proportions of text and groups of text.

5.3 THE ORGANISATION

The category of the organisation comprises Queensland Health’s public healthcare facilities. In this category, three sub-components inform the organisation category including structure, process and tasks. The sub-components operate as inter-dependent elements that are distinctly balanced. If one element becomes unbalanced, an adverse trajectory develops (Vaughan, 1999). One hundred and nineteen statements were sorted into this category.

Manifest analysis of the sub-categories was applied to enumerate and identify patterns of text although it became clear during the enumerative stage that the sub-categories structure, process and task were closely interrelated. While some text clearly fitted best into a sub-category other text was sorted from the meaning of the sentence. Parts of text were entered into the sub-category. In this category, each sub-component data is described individually.

Refer to appendices E – the organisation category, for full data frames. Appendix F contains RCA recommendations that were sorted into another data frame. This data acknowledges solutions generated from the RCA that best fit to the organisation category.