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Students will critically analyse an infection risk management strategy, using the Root Cause Analysis Model, of an adverse, serious or sentinal event that has occurred in New Zealand in past three years (not the Havelock North gastroenteritis outbreak (2016).
A root cause analysis is defined as a retrospective approach to error analysis, the investigation of the direct or original error that led to an adverse event (Infection Control Today, 2006).
Aims of a route cause analysis:
• Seeks to identify the origin of a problem using a specific set of steps
• Determine what happened
• Determine why it happened
• Figure out what to do to reduce the likelihood that it will happen again
Students will:
• Describe what happened (provide a narrative description of the event).
• Create a timeline of events (flowchart the actual sequence of the event, and attach as an appendix.)
• Study what happened (collect relevant information related to the event).
• Discuss what were the Key Causal Factors? (Why did the infection occur?).
• Discuss what processes, environmental factors, social factors were involved in the event or could have contributed to the event?
• Discuss what risk management strategy/model was used? (How successful was it? issues?)
• Discuss what steps were taken to control infection? Discuss six steps that were taken to control the spread of the infection, and assess if these were effective?
• Discuss what changes need to be made to prevent this occurring again?
• Identify what measurements/data needs to be collected to track improvements of the infection or systems?
Learning outcomes:
1. Critically evaluate contemporary theories related to infection risk management and its application to practice.
2. Design and critique tools to promote quality assurance for their use within health-related infection risk management. 3. Evaluate the role and use of evidence in infection risk assessment and manage. E: Students must submit their assessment to the Moodle Dropbox.
Root Cause Analysis (Report format)

Executive Summary
Table of Contents
1.0 Introduction
2.0 Narrative description of the event
3.0 Timeline of events (Flowchart format)
4.0 Study what happened (Cause and Effect diagram)
5.0 What were the Key causal factors: 5 Why’s
6.0 Processes and environmental factors.
7.0 Risk Management Strategy
8.0 Steps to control infections- six steps
9.0 Changes need to be made
10.0 Measurements and data need to be collected.
You can write upto 1700 its report format

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