Making Every Baby Count

There are multiple tools available for completing a root cause analysis. One of the most
helpful is called an Ishikawa diagram, which is also known as a “fishbone” diagram,
because a completed diagram can look like the skeleton of a fish (see Figure A4–1).
Steps for a group to complete a root cause analysis through a fishbone diagram:
Step 1: Record the event at the head
The first step is to identify the problem or event – for example, a death with a specific
cause, such as an intrapartum-related perinatal death in a full-term baby. Write this problem
in a box on the far right-hand side of a large sheet of paper as the “head” of the fish, to
represent the event that is under investigation for contributing problems and factors, and
then draw a line across the paper horizontally from the box as the “spine” of the fish.
Step 2: Brainstorm contributing factors
Next, draw lines as “bones” off the spine of the fish with a box at the end of each line/
bone in which to write down the contributing factors. The group then attempts to identify
the problems and factors that led to the perinatal death. These may be problems at different
levels of the health systems, or system building blocks such as staffing, equipment,
information, etc. Identifying the contributing factors is typically done through open brainstorming,
with every person in the group contributing out loud everything that they can
think of that contributed to the occurrence of this death. Alternatively, instead of contributing
out loud, groups may choose to have participants write down what they think the
contributing factors to the death were and then submit them anonymously to a discussion
leader who can read them out loud.
The National Health Service (NHS) of England has developed a list of potential contributing
factors which is is provided to participants in its National Patient Safety Agency to
FIGURE A4–1. Fishbone diagram
94 MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS