Individual Root Cause Analysis of the 25 incidents selected as the sample

1. Research process flow diagram. ‘Root Causes of Adverse Drug Events in Nursing Home Residents With Diabetes: Enhancing Safety in Medicines Management’ PB-PG-1010-23040 (20-3-13) Pre-initiation preparation – Ethical and R&D approval Months 0 Recruitment of nursing homes, permissions and RCA training for research assistant. Canvass to identify diabetic medication ADEs in participating Nursing homes and through NHS community services 4 *Score 1 to 3 on NPSA Risk Matrix scoring system Narrative description of identified adverse drug events created and each event is ‘risk scored’ (likelihood x consequences) (NPSA, 2008) *Score 4 to 25 on NPSA Risk Matrix scoring system Low risk events are excluded from the RCA study element Individual Root Cause Analysis of the 25 incidents selected as the sample 20 Output 1- Summary narrative feedback an applied learning report for NHS providers and participating nursing homes Meta/thematic content analysis of the 25 RCAs including the identification of error types and latent factors *Score 1 - 3 = Low risk 4 - 6 = Moderate risk 8 -12 = High risk 15 - 25 = Major Output – 2 All individual confidential RCA reports circulated to relevant NHS providers and nursing home Output - 3Significant root causes and error types identified and reported Output - 4Solutions for patient benefit identified, risk assessed and reported Output – 5Safe/good practice identified and reported as exemplars Output - 6 Model created of good medication practice. Design and procedure changes recommended. 30 Final research report = Outcomes 1 to 6 combined