Development and use of an on-line tool for completion of MRSA bacteraemia root cause analysis

Hardy KJ, Gossain S and Penny A

Objectives

To develop an on-line tool that allows timely and targeted completion of a root cause analysis investigation (RCA) for MRSA bacteraemia cases within an acute hospital setting.

Methods

For all MRSA bacteraemia cases in England there is a requirement to complete a RCA. The process in our Trust involved completion of a paper form which was sent back to a central point for analysis. This resulted in partially completed forms, with varied data being provided. Completion and data entry for analysis were time consuming and the missing data meant the analysis was not standardised and resulted in difficulties in trend analysis. Using web based technology an on-line form was designed to overcome these pitfalls.

Results

Development of the on-line web based form allows the entire RCA process to be completed electronically. Initially the electronic form is populated with personal identifiable information and then links to other hospital based systems to acquire information about ward movements. The users are then taken through a series of targeted questions to establish risk factors and focus of infection, identify lessons to be learnt or where non-compliances with policies have occurred. All of the questions either have drop down boxes with options, or are date and time fields to enable meaningful analysis and comparison of cases. On completion of the RCA, there are a series of verification processes, firstly by the user and then by the infection control team. If key questions have not been completed the user will be asked to return to these. An action plan must be developed to cover the key learning points, for all actions the person responsible is nominated and the action plan link sent to them. On completion a comment is placed on the system and once all actions relating to a specific RCA are complete the case is considered closed. All entries carried out on the on-line system are tracked with date, time and user allowing audit of the process.

Conclusion

The on-line tool is easy to use, resulting in a reduced time to completion and analysis of the findings. This has allowed us to analyse and interpret the data enabling the introduction of targeted and effective infection control measures.