Table 1.

Data entry instrument – asking whys model of root cause analysis (RCA)

Time line	Clinical data	Root causes and comments
Antenatal care period	Summary of ANC record with notes on significant events	What was the earliest significant event?
		How did it occur? Why?
		What was the next failure?
		How did that occur? Why?
		Why was this not corrected?
Admission presentation	Indications for clinic or hospital admission.	What factors were related to ANC? How?
		What factors contributed to outcome? How?
	Summary of clinical record.	Why did they occur?
	Notes on significant events.	Why was this not corrected?
	Was the diagnosis correct?
Death	Cause of death given in the notes [clinical or post-mortem]	Consensus on most probable cause of death. Was death avoidable? How?
Root cause analysis: adapted from National Patient Safety Agency [15]
1. Patient characteristics: pre-existing or co-morbid medical conditions, physical limitations, language and communication barriers, cultural issues, social support needs that play a role.
2. Task factors: What protocols and procedures are in place for labor and delivery, for use of analgesia, for dystocia, for C-sections? Are they safe? Are they practical? Are they effective? Are they consistently applied?
3. Individual staff: How did the knowledge, skills, training, motivation, and health of patient’s providers affect her care?
4. Team factors: How well do the various health care professionals involved in patient’s care work together? What is the nature of the communication? Are there hierarchies? What is the responsiveness of nursing supervisors or attending physicians? How easily can a team member ask for help or clarification?
5. Work environment: Is the labor and delivery unit adequately staffed? What is the workload? What is the staffing level of experience, functionality of the equipment, quality of administrative support?
6. Organizational and management factors: How do the values of the hospital translate into clinical practice? Do their standards and policies focus more on patient safety and quality of care, or volume and speed? Are management’s priorities patient- or provider-centered? Does senior leadership foster a culture of teamwork and safety or blame and shame?
7. Possible solutions: