A Root Cause Analysis Of Case Study Six

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Root Cause Analysis of Case Study Six A root cause analysis is a systemic approach to identify problems within an event in an effort to help prevent them from recurring in the future to another patient. To be effective this analysis should include a timeline. This timeline is created to promote the identification of those areas that may be the cause of the problem or event. This timeline should also explore the relationship between the causal factors and those factors identified to be the cause for the event to have ever occurred. According to The Joint Commission (TJC), a root cause analysis should focus “primarily on systems and processes, not on individual performance” (The Joint Commission, 2013). The purpose of this paper is paper is…show more content…
The first factor is the questionable medical necessity for the procedure being performed in the first place. The rationale for the procedure provided to the family for the ERCP was ‘’’acid reflux’’’ (Johnson, Haskell, & Barach, 2016, p. 74). This explanation as described in the case study does not appear to meet the standards established by the Texas Health and Human Services on informed consent. The physician failed to advise the patient of the “risks or hazards that could influence reasonable person” (Texas Department of State Health Services, 2017). According to Elmunzer, 3-15% of ERCP cases result in pancreatitis with substantial morbidity. The cost for treating pancreatitis as a result of having had an ERCP exceeds 200 million dollars annually in the United States alone. They recommend careful stratification of the risks versus benefits on each patient (Elmunzer, 2017, p. 01). The second identified area where the process broke down was when the patient’s family called the hospital to tell them that she was having emesis and severe pain rated nine out of ten. The triage nurse instructed them to take Tylenol and informed them that the physician was unavailable. The physician eventually called back and instructed them to give her one Tylenol and some soup. In this stage, the physician downplayed the concerns and did not consider the possibility of pancreatitis, the most frequent complication after having had an ERCP (Johnson, Haskell, & Barach, 2016, p. 80). The
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