Characteristics Of A Root Cause Analysis

Nightingale Community Hospital identified a recent sentinel event involving the ambulatory surgical center. A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (http://www.jointcommission.org/sentinel_event). A three year old female presented to the hospital on September 14th for a planned outpatient procedure. The child was accompanied by her mother. The mother registered the patient with the registrar prior to the procedure. The patient and her mother went to the pre-operative area to complete the informed consent and the necessary physical assessment. The pre-operative nurse obtained the necessary contact

The reason for this essay is to reflect on a critical incident experience during my six week placement as a student nurse on an orthopedic ward. To explore an event as a critical incident is a value judgment, and the basis of that judgment is the significance attached to the meaning of the incident. Critical incidents are created or produced by the way we look at a situation. Tripp (1993)

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.

There must be a trust in the professionalism within the IC and the ability to maintain an unbiased attitude, understanding

This paper will analyze the cause of the sentinel event which occurred to Mr. B, a sixty seven year old patient which presented to the emergency room with left leg pain. A root cause analysis will be necessary in this case to investigate the causative factors which led to Mr. B’s sentinel event. The factors in this unfortunate case weather they were errors in his care, or hazards in the system will be identified. The Change theory will be used to develop an improvement plan that will be used to decrease the chances of a reoccurrence of the sentinel event that happened to Mr. B. in the scenario.

The goal of this paper is to scrutinize the regrettable sentinel event of Mr. B, a sixty-seven-year-old patient who was admitted to a rural ED with left leg pain that he found unbearable. A root cause analysis will be used to exam the causative factors that led to this unfortunate sentinel event. Then I will identify the errors or hazards in the care of Mr. B. A change theory will then be utilized to establish a useful improvement plan that would hopefully decrease the chances of a repeat of the outcome in the Mr. B scenario.  A Failure Modes and Effects Analysis (FMEA) will then be

3) Surgeon: Was directly involved in the events leading up to the sentinel event. The surgeon was responsible for all activities taking place in the surgical suite and directly related to the surgery of the pediatric patient. The surgery was completed safely and successfully; however, the surgeon had relevant information in the patient chart at his office yet did not share this information with the hospital. He also did not supply an appropriate or accurate H&P that would have included custodial status for the pediatric patient to the hospital. The surgeon is greatly concerned in the events that lead to the sentinel event and wants to ensure that his patients will be cared for and safe at Nightingale Community Hospital.

A.Nightingale Community Hospital is attempting to be in complete compliance with Joint Commission’s “communications” standards. Prior to the Joint Commission survey, Nightingale Community Hospital wanted to focus on items UP.01.01.01 through UP.01.03.01 of the Joint Commission handbook. According to the handbook, these items focus on the universal protocols for preventing wrong site, wrong procedure, wrong person surgery (2015). In response to these universal protocols, the hospital implemented a pre-procedure hand-off tool, which is completed and signed off by both the nurse handing off the patient as well as the nurse accepting the patient. The hospital also began

Taking time to conduct a proper analysis of the cause eliminates a premature conclusion that may lead to inadequate corrective actions (William, 2008). A root

The first project of ENG W231 entailed understanding the purpose of the ACE process, professionalism, communication through different mediums, and ethical considerations. I was to apply my understanding through three different scenarios. This memo summarizes the process of completing project one and the additional knowledge learned.

Horkan, A. M. (2014). Exploring the Evidence Alarm Fatigue and Patient Safety. Nephrology Nursing Journal, 41(1), 83-85.

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).

The purpose of this paper is to analyze the unfortunate sentinel event of Mr. B, a sixty-seven-year-old patient presenting with severe left leg pain at the emergency room. A root cause analysis is necessary to investigate the causative factors that led to the sentinel event. The errors or hazards in care in the Mr. B scenario will be identified. Change theory will be utilized to develop an appropriate improvement plan to decrease the likelihood of a reoccurrence of the outcome of the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA) will be used to project the likelihood that the suggested improvement plan would not fail. Lastly, key roles nurses would play in improving the quality of care

Chosen for root cause analysis is case study number 18, titled “Not for IV Use: The Story of an Enteral Tubing Misconnection” from the book Case Studies in Patient Safety: Foundations for Core Competencies. Root cause analysis is a process whereby error producing system factors are identified and reviewed to assist in the formatting and implementation of solutions to prevent similar errors from reoccurrence (Wachter, 2012). This accounting of the patient’s experience located in the Systems-Based Practice (SBP) section also highlights various code of ethics violations such as autonomy, beneficence, nonmalfeasance, and veracity. The SBP approach in healthcare requires that personnel recognize how patient care connects to the entire health care system and how to utilize successfully system resources to improve both quality and patient safety. There are specific core competencies that assist with this process. Some of which include the ability to work effectively in the delivery-care setting, perform responsibilities according to role, ability, and qualification, advocate for quality patient care and resources, and participate in error identification and solution implementation (Johnson, Haskell, & Branch, 2016). This patient’s story demonstrates an apparent failure of these core competencies.

Discuss how an understanding of nursing-sensitive indicators could assist the nurses in this case in identifying issues that may interfere with patient care.