Clinical governance report

Write a ‘Formal Investigative Report’ about a critical incident that has occurred.

Please use the below as a guide of what to include in this report;

Introduction/Background to the Incident: A short introduction including what the report is about followed by a brief background to the critical incident. Using the Severity Assessment Code (SAC) Matrix allocate a rating and explain why you gave this score.

Factors/ Flow chart: Critically examine the case to identify and explore all the predisposing factors that lead to the outcome, these factors are the ‘root causes’. This information needs to be supported by a flow chart with annotations to present the complex details of the incident in an easy to view format.

Analysis: Analysis of the information presented in the ‘factors’ section can be referred to as a ‘root cause analysis’ (RCA). The predisposing factors are explored in regards to why they existed and how they lead to the incident. Any relationships between the factors is also explained. Use a ‘patient safety model’ diagram to demonstrate the factors that were the root causes that lead to the incident and to identify factors that if mitigated would have prevented the incident from occurring.

Discussion: In this section of the report current evidence-based peer reviewed literature is explored in relation to the incident and the root causes of the incident to develop a deeper understanding of the why the incident occurred, what should have happened and how it could be prevented in the future. The NMBA competencies should be discussed in relation to professional best practice with two (2) relevant competencies being explored further. The literature discussed needs to be of a high quality and be current.

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Recommendations: Evidence-based recommendations are made, which if implemented correctly would prevent the same 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.