The sample comprised completed RCA documents (hard-copies). The RCAs were extracted from various Queensland Health facilities that utilise the PRIME CI to report
incidents. Only SAC 1 events formally commissioned to RCA and completed and lodged with the PSQ custodian were included. The total sample size comprised 48 RCAs.
Eight RCAs were purposively selected from each of the years 2009, 2010 and 2011.
It was expected that each RCA would consist of 10 to 20 pages of text. On examination of the sample, the average document comprised 4 to 8 pages. Therefore, because the numbers of pages of data were less than expected, a further twenty-four RCAs, eight per year, were therefore added to the sample to comprise a total sample of 48. This sample of approximate 10% of completed RCA annually was deemed appropriate by the supervisory team in response to a declining rate of completed RCAs annually One document was excluded from the second sample because the analysis technique applied Human Error and Patient Safety analysis and not RCA.
The sample was determined purposeful because RCA documents completed prior to 2007 may not have yielded consistently presented data or descriptive detail as deemed by the 2007 amendments of the Health Service Act (1991). In addition, the Health and Other Legislation Amendment Act (2007) required the inclusion of a 4B Root Cause section. For these reasons and a new quality checking process established by the Patient Safety Centre, RCAs from 2009 to 2011 were selected. As analysis proceeded and where indicated, further RCAs were sampled within the same timeframe to address theoretical developments.
According to the Learning to Action Report 2012, ‘summary data’, 657 SAC 1 incidents were recorded for the period 2009 to 2011(Queensland Health, 2012, p. 12-13). Of these SAC 1 events, 291 proceeded to RCA (Queensland Health, 2012, p. 17-18). From this data, the sample comprises 16.49% of completed RCAs; date ranges for the selection of RCAs for the research may be inconsistent with the Queensland Health, 2012 report. The researcher and supervisory team determined the sample size sufficient for an in-depth theoretical analysis and the formatting of the RCA reports consistent and compliant within legislative conditions.
4.3.1 Inclusion criteria
A number of inclusion criteria informed the sample. An RCA may be commissioned on any event. In this study, the focus was SAC 1 events and therefore only SAC 1 clinical incidents that complied with the legislative definitions and criteria established by the Queensland Health Services Act 1991, the Queensland Health & Other Legislation
Amendments Act, 2007 and the CIMIS (Queensland Health, 2009a), constituted the sample.
The selection criteria determined that the RCA sample comprised the following:
• SAC 1 clinical incidents;
• Accompanying RIB and Commissioning authority modus operandi;
• Representative of the time frame from the Reportable Event date to inclusive of 2009–2011;
• The completed RCA, lodged with PSQ.
• A completed RCA document may comprise three sections (Health and Other Legislation Amendment Act, 2007)
• Root Cause Analysis report pages 1–4 (description of event, causal statement, recommendations, lessons learned).
• Chain of Events Document 1 (Final flow diagram) (Health and Other Legislation Amendment Act, 2007, Part 4B, s38M).
• Chain of Events Document 2 (Contributing factors diagram) (Health and Other Legislation Amendment Act, 2007, Part 4B, s38M).
All sections of the RCAs were included in the analysis. The legislative conditions established that the Patient Safety and Quality Unit clinical incident management team applied a random data collection process to the RCA sample.
4.3.2 Legislative conditions
In this study, only RCAs that had formally progressed to the commission authority with an endorsed Reportable Incident Brief (RIB) and complied with state-wide legislative processes were included. The selection of these RCA documents served to reflect a
consistent level of harm according to Queensland legislation and provided some rigour and consistency given that an RCA may be conducted on SAC 2 or SAC 3 events.
The RCA sample was retrieved by the RCA custodian and from the PSQ data archive. These documents were not accessible by the researcher due to legislative provisions.
The RCA documents remained in the original hard copy format and were not copied in part or in full (Health Services Act, 1991). The RCA documents could not be removed from PSQ, Block 7, Level 14, RBWH. Therefore, the researcher was required to analyse all data on-site within the PSQ unit.
The RCA is legislated under the Health Services Act (Qld) (1991) Part 4B. Access to RCA reports is regulated under the Health Services Regulation (2002). The researcher signed
an agreement to comply with the legislative statutes of the Queensland government prior to undertaking the research as well as compliance to ethical/legal considerations, inclusive of the chain of event documents part 1 and 2.
The researcher and the principal supervisor were appointed as honorary employees (unpaid) to the PSQ to meet the legislative requirements set out in the Health Services Regulation (2002).
4.3.3 Supplementary sample information
Only Queensland Health public healthcare facilities that engaged the PRIME clinical incident management system were sources of data. The voluntary lodgement of these
incidents (SAC 1) occurred on the sites of Queensland Health facilities participating with PRIME CI.
Queensland Health staff voluntarily report approximately 300 SAC 1 incidents each year. An SAC 1 clinical incident is defined by the CIMIS (Queensland Health, 2009a, p. 29) as “death or likely permanent harm, which is not reasonably expected as an outcome of healthcare”. “Not reasonably expected” is explicitly understood to include the reasonable expectation of treating clinicians, the patient or family (Queensland Health, 2012, p. 15). In the event of an SAC 1 incident, each healthcare facility has an authorised delegate to
‘commission’ the SAC 1 incidents. This person is called the ‘Commissioning Authority’.
When an SAC 1 clinical incident is lodged into PRIME CI the Commissioning Authority may or may not commission the incident to proceed to RCA.
Of approximately 300 SAC 1 events reported annually, in 2009-2010, 49% SAC 1 events proceeded to RCA. In 2010-2011, 41% of SAC 1 events proceeded to RCA
(Queensland Health, 2012) and “a trend away from using RCA” is acknowledged
(Queensland Health, 2012, p. 18). Despite this, completed RCAs are filed electronically by the PSQ according to a Reportable Event (RE) number which is drawn from a numeric system, established in 2005, of ascending numbers. This number is identifiable only to the PSQ reportable event team. The RE numbers were irrelevant to the researcher and the research. The RE number has been applied by PSQ to RCA documents as a method of identifying the reports and does not name the health service district or provide location information, patient details, or the RCA team membership. However, should issues have arisen through the analysis of the text the researcher would have escalated the concern through the appropriate organisational channels.