Root cause analysis process will utilize a systematic step-by-step approach to help identify all causative factors leading to this sentinel event. The main purpose of the Root Cause Analysis is to understand how the event happened, why did it happen, and what can be done to prevent an event from happening again. The first step, collect all necessary data associated with this event such as: current policy and procedures, incident report, Mr. B’s health history, environmental flowcharts, dispensed medications, equipment and staffing factors relevant to the event. The process of identifying causative factors can begin once all the data is collected. The goal, of a Root Cause Analysis, is to identify interventions to prevent an event from reoccurring.
This review is to discuss an overview of this case study with a clinical reasoning model and all contributing factors of this event. Then, the critical analysis of three articles relating to the factors with the reasons for the selection and their evaluation will be presented.
The case-control study was used for HIV infection and fracture risk to explore the existing association between these diseases and excess risk of clinical features. The studies have reported an association between HIV infection, antiretroviral therapies, and reduce bone metabolism; the fracture risk data impacts are insufficient. The data from Danish National health service registries by conducting a case-control study, including 124,655 fracture cases and 373,962 age and gender matched controls. The cases and controls were arising from the same population and controls were selected randomly for each case up to 3 controls, and the incident cases were selected. The confidence intervals 95% and odds ratio were estimated using conditional logistic regression. In this
The third step of root cause analysis process is identifying possible causal factors (Mind Tools, n.d.). In this step, the team would determine the factors that contributed to the event. In the given scenario, the factors that led to Mr.B’s sentinel event were his tolerance to pain medications and clinical situation (age, weight, and kidney function) were not considered. The emergency department was very busy and understaffed which caused Nurse J to leave the room and unable to monitor the patient closely. Another factor was that the
A friend of mine went to the emergency department because she had severe pain in her right lower abdomen. She received a laparoscope and was notified that she required surgery immediately to get her appendix removed. While the on-call anesthesiologist was caring for a mother in labour leaving her and other patients waiting for care. She waited several hours to get access to an anesthesiologist to receive medical care before her surgical procedure. After her surgery, the surgeon stated her appendix was really severe, and they were lucky enough to perform surgery before it ruptured. If she had waited longer her appendix could’ve ruptured, and it would’ve been very dangerous and life-threatening. Based on this experience I will examine how
Causes of major medical errors have many different factors and influences. This includes why the patient was being seen to allow such an error, what medical guideline or guideline’s that where not followed that caused the error, what could have been done by staff members to prevent the error, etc. When errors take place, repercussions follow such as the cost incurred to the patient or patient family members, fines the medical worker must pay, and most importantly what is the patients status/prognosis. Not all patients prevail and make it through such awful medical errors.
On 6/11/15 at 2:00 pm, I called Dr. McClain at his listed home number to confirm he was still in the area and to inquire if he would be available for an interview at some point. Dr. McClain began explaining that to his knowledge all of the complaints had been “kicked out” except for one case involving an ileostomy reversal. That complaint resulted from him being told not to have contact with patients since he was under investigation. The patient was upset because they could no longer see him, McClain stated.
Elliott, M., Page, K., and Worrall-Carter, L. (2012). Reason’s accident causation model: Application to adverse events in acute care. Contemporary Nurse, 43(1), 22-28.
After careful analysis of what had happened and what should have happened takes place, the RCA team should ideally focus on why the adverse events happened. In this step, the goal is pinpoint the direct causes and contributory factors (Ogrinc & Huber, 2013). By doing this, the root cause of an event can be identified. One suggestion made by the Institute of Healthcare Improvement in the root cause analysis process is to ask “Why?” five times (Ogrinc & Huber, 2013).
In the root cause analysis, the root cause analysis team investigates the role of multiple factors that could have contributed to the event, such as communication, equipment failures, staffing levels and/or fatigue, training, policies/procedures, and organizational culture. Following the analysis, the facility must implement a corrective action plan to implement the findings of the analysis or at least report to the appropriate state department any reasons for not taking a corrective action plan. The findings of the root cause analysis and a copy of the corrective action plan must be filed with the commissioner within 60 days of the event for the State of Minnesota. The team of clinical and quality improvement experts review the root cause analysis and corrective plan meet all criteria and that the facility is able to take steps to reduce this risk of any future adverse events. The review team will provide feedback to the facility and allow modifications to be applied until all criteria have been met. Each event can go through up to three reviews (Minnesota Department of Health,
Mr. Clifford a 57 years old Hispanic patient presents to the urgent care, complaining of episodic epigastric discomfort, which he describes it usually begins a few hours after eating a meal. The patient, also reports other symptoms such as heartburn, bloating, abdominal fullness and indigestions. The patient reports the pain wakes him up at night and he feels some relief after taking antacids. Mr. Clifford agrees to take aspirin prophylactic
A medical diagnosis was a small distal bowel obstruction. The patient was NPO, on an NG tube, and IV fluids. The patient was also bipolar, which was a learning experience. The patient had an incision lower abdomen from umbilical region down to the pelvic region. It was approximately 10 cm. The nurse measured her NG to ensure it was in proper placement. She encourage the patient to eat ice chips to decrease cotton mouth. The nurse educated the patient on how ambulating will help the bowels to move and relieve abdominal pain. The nurse auscultated the patient’s bowel sounds to ensure the bowels were active. The nurse also had the patient use an incentive spirometer. This is to ensure the patient does not get pneumonia which would compromise the healing process. The nurse strongly encourage the patient to suck in air slowly through the mouth piece. The patient was able to such in 1000 for inspiratory volume. This was doubled from yesterday which was only 500. (Bunker Rosdahl, 2012)
Anna is a fifty five year old homeless, unemployed woman who was admitted to the Emergency Room (ER) at Victoria Hospital in London, Ontario for pelvic pain and postmenopausal bleeding. During the nurse’s head-to-toe assessment it was found that the patient also had presenting abdominal distention, prompting her physician to order an X-Ray to determine if a gastrointestinal issue caused this distention. Once this was ruled out, Anna’s physicians continued to search for the underlying cause of her abdominal distention, in addition to her other admitting symptoms. As a result, Anna was admitted to the hospital as an inpatient on the Acute Medicine Unit. The day following admission, Anna went for further testing to hopefully discover the cause of her symptoms. The first test completed was an
I am uncomfortable putting work conflicts on the internet, and even more uncomfortable exposing personal relationship conflicts that should inherently be private. I also do not watch the news, because I do not trust it as a source of information. Thus, for the purposes of this essay, I shall describe the most recent inner conflict of note that I have experienced instead, and analyse it using the “Root Cause Analysis” and “5 Whys” strategies that were discussed in this week’s reading.