Root cause analysis investigation of community pressure ulcers
Research type
Research Study
Full title
The development of an empirically derived root cause analysis protocol for the investigation of pressure ulcers acquired in patients receiving nursing care in their own homes
IRAS ID
204432
Contact name
Caroline McGraw
Contact email
Clinicaltrials.gov Identifier
NA, NA
Duration of Study in the UK
0 years, 4 months, 1 days
Research summary
Pressure ulcers (PU)are an indicator of nursing quality because they are often avoidable. For this reason, they are subject to a root cause analysis (RCA) investigation. The purpose of investigation is to identify what went wrong in care delivery and make recommendations to prevent harm to future patients.
RCA protocols have been developed to guide the conduct of avoidable injury investigations in healthcare (such as investigations into surgical errors). These protocols are derived from medical publications on risk management and adverse incident investigations in high technology industries. They have also been adapted to guide the conduct of PU investigations by incorporating questions relating to the factors identified by biomedical science as leading to PUs.
Whilst widely used by home nursing services, there is evidence to suggest these protocols were designed with hospital contexts rather than home healthcare settings in mind (for example, they ask about the amount of time patients spent on operating tables). Yet, there may be different and/or additional factors in home nursing which lead to PUs that do not currently feature in the literature; for example, factors associated with non-nursing activities that are critical to PU prevention (such as assistance going to the toilet etc.) being met by family members or paid carers operating at a distance from nursing services.
This qualitative study seeks to detect these different and/or additional factors. Interviews will be conducted with a sample of nurses working with patients in their own homes. Interviews will be digitally recorded and transcribed. Participants’ accounts will be analysed to categorise the factors relating to pressure ulcer development in home settings. If distinct from those identified in existing PU RCA protocols, these categories will be used as the building blocks of a new RCA protocol for the investigation of PUs acquired in home healthcare settings.
REC name
N/A
REC reference
N/A