Root Cause Analysis

Environmental Factors: The hospital is a very busy place. The background noise can distract the attention of the physicians while they ponder over the right prescription of a drug. The high demand of a medical profession can be stressful and lead to fatigue. These possible occupational hazards can contribute to medical errors.

The main objective of Beaumont Hospital is to provide high quality, efficient, accessible services, in a caring environment for Southeastern Michigan residents. Beaumont Hospital believes that patient safety is just as important as medical progression. Therefore, Beaumont Hospital’s risk management program consists of identifying hazard associated risks, controlling risks, and monitoring the effectiveness of procedures/practices. Risk is a part of patient care and services because everything doesn’t always go according to plan. Catastrophic patient injuries often occur because of unanticipated failures. The risk management team is responsible of effective surveillance, analysis, and prevention of events which may injure patients, lead to malpractice claims, or cause loss to the health care system. The risk management staff at Beaumont use the Failure Mode and Effects Analysis (FMEA) as a tool to anticipate what might go wrong with a process or product and how that failure effects the patient. FMEA is designed to dissect a particular process into its individual steps, isolate the potential steps that could cause the problem, assign a specific risk level to each abnormal step, analyze the risk potential for the process, and assign and action plan to correct the problem (Fibuch & Ahmed, 2014). The risk management team also evaluates and modifies potential problems. Beaumont Hospital’s risk management team helps avoid or eliminate risks by identifying an alternate

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.

The process is an action plan that tends to illuminate on the strategies to be employed with the purpose of reducing the risk of a similar sentinel event such as that of Mr. B’s scenario. It addresses the responsibility for the oversight, implementation, pilot testing, as well as timelines and strategies for the measurement of actions that are effective (Lewis et al, 2014). All the root cause analysis (RCA) findings conducted above should help in the determination of the appropriate action plan. The appropriate improvement plan in this scenario should encompass the reevaluation of the events that led up to the code blue of Mr. B. The plan should look at the staffing mix, if the licensed personnel are trained appropriately, the patient to nurse ratio in the ER and the types of patients that were in the ER at the time. When

The main objective of healthcare professionals is to provide the best quality of patient care and the highest level of patient safety. To achieve that objective, there are many organizations that help improve the quality of care. One of the best examples is the Joint Commission. Unfortunately, the healthcare system is not free from total risks. In healthcare activities, there are possible errors, mistakes, near miss and adverse events. All of those negative events are preventable. But, it is clear that errors caused in healthcare result in thousands of deaths in the United States.

A root cause analysis is a systematic approach utilized to identify problems within an event and create a plan for preventing that problem from recurring in the future. To be effective, a timeline of the events are created to help identify those areas that may be the reason for the problem or event, and the relationship between the causal factors and those factors identified to be a reason for the event to have occurred.

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

Root cause analysis (RCA) is used in different fields to conduct a systematic search to find the causes of a specific sentinel event (Jacob, 2010).  The main goal for conducting a RCA is to prevent similar adverse events from happening in the future (Jacob, 2010).  In this paper, I will use the scenario provided in the task to create a complete RCA report as well as improvement plans that will prevent similar incidents from happening again.

The provided scenario gives an account of a busy emergency department with competent staff, and the multiple errors that led up to the most severe error possible in healthcare, unnecessary death of a patient. A root cause analysis (RCA) can be utilized to help understand the systems at fault within the facility so that improvements can be determined and implemented to prevent any future occurrences (Cherry, 456). RCAs focus on systems rather than blaming individuals involved, therefore they are only appropriate in cases where there has been no willful negligence or criminal acts (Huber & Ogrinc, 2014). The overall purpose of RCAs is to find out the causes of the adverse event and determine how to keep similar errors from

A root cause analysis (RCA) is a method by which we can examine a serious adverse event and identify the cause, or causes, that led up to the event. Although personnel are involved in these events, the primary purpose of the RCA is to identify the cause, not to assign blame (Agency for Healthcare Research and Quality, 2014). It is through identifying a cause, or causes, of an adverse event that we can improve on patient care processes and thereby patient safety. The RCA is designed as a specific protocol that starts with data collection looking at the sequence of events that led to the

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

An IRS can provide valuable insights into how and why patients can be harmed at the organizational level (Pham, Girard, & Pronovost, 2013). According to the Joint Commission, IRS can be use for quality improvement, it provides opportunities to coordinate patient and worker safety improvement and provide data that supports combined patient/worker health and safety issues. Incident reporting systems “highlights the value of having frontline staff participate directly in the design and planning stages of safety reporting systems and improvement activities” (The Joint Commission,

The authors relied heavily on two studies to create their argument. The first study mentioned was the Pinto et al article. In this study, "Pinto and colleagues (5) assessed the

• Many challenges stem from not understanding how to navigate many of the health systems. (Seniors may not be able to navigate the complicated healthcare systems).