From a clinical governance and quality assurance perspective you are to write a report about a critical incident that has occurred.
A critical incident report using the headings below is required. As this is a formal report please use professional language of an academic standard and support your writing with appropriate and current references. Introduction/ Background to the Incident: A short introduction including an overview/summary of the incident and what the report will contain. Severity Assessment Code (SAC) rating: – Using the Severity Assessment Code (SAC) matrix allocate a rating and explain why you gave this score. Analysis of Factors: Review the information presented within the critical incident scenario and identify factors that contributed to the incident occurring. Identify any relationships between contributing factors. Reference to current evidence-based peer reviewed literature and contemporary initiatives should be explored in relation to the incident. Analysing the factors will allow you to discover the ‘root causes’ of the incident which will support you to develop a deeper understanding of the why the incident occurred, what should have happened and how it could be prevented in the future. Patient Safety Model: There will be a range of predisposing factors that have contributed to this critical incident scenario. You are to select one of the patient safety models that have been discussed in the modules and apply this to this critical incident i.e., fishbone model OR Heimlich model OR Swiss cheese model. The ‘patient safety model’ diagram should demonstrate the factors that were the root causes that lead to the critical incident. Links to Professional Standards: From your analysis above discuss the implications for nursing practice. Refer to the NMBA Registered Nurses Standards for Practice, professional codes and other evidenced based contemporary initiatives drawn from either the literature or practice. Recommendations in relation to Quality Improvement, Clinical Governance Initiatives and RN Professional Standards: Evidence-based recommendations are made, which if implemented correctly would prevent the same critical incident from occurring again. Literature which supports the recommendations needs to be presented, otherwise the report will have little credibility. Any recommendations must address the identified pre-disposing factors, in particular the ‘root causes’ and explain how the recommendations will mitigate these factors using a clear and logical approach. Referencing – American Psychological Association (APA). (2010). Publication Manual of the American Psychological Association (6th ed.). Washington DC: APA.
