Making Every Baby Count

assist them when brainstorming circumstances around adverse patient events, in the
course of completing fishbone diagrams. These factors include: 9
• Team factors: role congruence, leadership, team cultural factors, team support factors;
• Organizational and strategic factors: organizational structure, organizational priorities,
and culture of safety;
• Communication factors: verbal, written, non-verbal, and communication between management
and staff;
• Working condition factors: administrative, design of physical environment, environment,
staffing, workload, hours, and time;
• Task factors: guidelines, procedures, protocols, decision aids, task design;
• Equipment and resources: displays, integrity, positioning, usability;
• Individual staff factors: physical issues, psychological issues, social issues, personality,
cognitive factors;
• Education and training factors: competence, supervision, availability, accessibility,
appropriateness;
• Patient factors: clinical condition, physical factors, social factors, psychological factors,
interpersonal relationships.
Step 3: Record the contributing factors at the end of the bones
After brainstorming, the next step is to write down each contributing factor in a box at the
end of a bone leading to the head of the fish (the event).
Steps 4 through 6 are best performed one contributing factor – or one “bone” – at a time,
until each step has been completed for each bone before moving on to step 7.
Step 4: Brainstorm contributing causes within each bone
The next step is to repeat the brainstorming process with each of the bones (each of the
contributing factors), to identify possible contributing causes. What problems or factors
contributed to that specific problem or factor written at the end of the bone?
Step 5: Record contributing causes on the veins
Again after this round of brainstorming, the next step is to write down these possible contributing
problems or contributing causes as shorter lines or “veins “coming off each bone
of the diagram.
Step 6: Brainstorm contributing subcauses on the subveins
For each contributing cause that is large or complex, it may be best to break it down into
sub-causes, working from proximal to distal causes below. Therefore, further brainstorming
is undertaken for each of the contributing problems or causes written on the veins.
What problems or factors (subcauses) contributed to the specific contributing problem or
cause? These subcauses – as well as any additional problems or factors that contributed
9
The list of contributing factors is adapted from Root cause analysis investigation tools: contributory factors classification
framework. NHS National Patient Safety Agency; 2009 (http://www.nrls.npsa.nhs.uk/resources/?entryid45=75605,
accessed 25 July 2016). This contributing factors list is not meant to be comprehensive, but to assist brainstorming.
MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS
95