Root Cause Analysis

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.

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.

A search of the Cinahl, Medline, Embase, BNI, psycINFO databases were made using the following key words, pain assessment, pain management, elderly, dementia and palliative care. The reference lists of identified papers were also searched for relevant articles. The use of many databases was deemed necessary due to

Pain is one of the most common and feared complications of cancer. It is exacerbated by stress, anxiety, fatigue, and malaise which accompany advanced cancer. Pain is generally absent in the early stages of cancer, but it is a significant factor as the illness progresses to advanced stages. Cancer-associated pain can arise from a variety of direct and indirect mechanisms including direct pressure, obstruction, and invasion of a sensitive structure, stretching of visceral surfaces, tissue destruction, infection, and inflammation (McCance 2010). Pain is generally accepted as whatever the patient says it is, wherever the patient says it is. Treatment of pain and its associated symptoms is a primary responsibility of the healthcare team. Treatment modalities for pain include the use of opioid analgesics, patient-controlled analgesia, psychological interventions, and preventing recurrence of pain. Reinforcing the reporting of pain by the patient is important, as is a respect for the social and cultural differences with respect to pain perception.

Step one, Geraldine pains will be monitored and documented at a regular interval by asking her to score her pain on a scale of (0-10) with 0 meaning zero pains and 10 being highly in pain. This will help in evaluating her cancer-related pain symptoms, which may involve viscera, nerve, or bone tissue. Use of rating scale aids helps in assessing level of pain and provides a tool for evaluating the effectiveness of analgesics, enhancing patient control of pain. Geraldine’s reported and unreported pain will be assessed. The discrepancy between reported and nonverbal cue can give us clues to the degree of pain, the effectiveness of

Sentinel events occur, but finding out the root cause of what may happened is used to improve patient safety. According to the National Patient Safety Foundation (2015), “RCA is a process widely used by health professionals to learn how and why errors occurred,” and “investigating the event in question with the intent of eliminating the possibility or reducing the likelihood of a future similar event.” The most crucial step in the root cause analysis and action process is to identify actions to eliminate or control vulnerabilities and hazards from the cause of death (RCA2 Improving Root Cause Analyses and Actions to Prevent Harm, 2016).

Identification of pain has been the most feared and common symptom of cancer (Sloan, et al. 1999). The joint project that includes primary, secondary and tertiary levels of care were successful in breaking down the barriers that crossed traditional boundaries in cancer care. Steering committee member were identified and meetings took place between multi-professional teams and project coordinators to identify their issues and concerns and communication, discharge, pain management and symptom control were identified. Multidisciplinary groups worked were

McDonagh (2013) stated that pressure ulcer is a one of the indicator to represent of quality of patient care. University Hospitals Coventry and Warwickshire Trust in England carried out a special campaign to prevent and to remove avoidable pressure ulcer with use of several strategies such as “Root cause analysis and performance review, equipment gap analysis, “documentation review, review of staff education, 100 Days free campaign, and use of social media” (McDonagh, 2013). McDonagh (2013) mentioned that “Root cause analysis and performance review” is an analyzing tool for patient safety incidents thus it helps to prevent safety incidents. During this special campaign, nursing staff’s education was empathized and Tissue Viability Team developed

In conclusion pain management is an important impact on patient practice as well as education and knowledge. Although the study did prove to have been beneficial I found the results to be inconclusive as they were generally biased according to the perception of the patient on the individually nurses’ influence and actions toward the management of pain. Every nurse in each generation can learn the same information and the same execution it is what the nurse chooses to apply of his or her own attitude that will determine how the patients will perceive their care and this is with any study being performed on the nursing practice with patient.

Nurses have a unique role in alleviating the pain experienced by their patients. With their professional knowledge and regular close contacts with patients, they are ideally placed to listen and respond to any concerns. Taking time to assess the individual will allow for the development of a thrusting relationship between the nurse and patient. Accurate assessment and documentation can help to chart the multi- dimensional nature of the pain, aiding decision making and patient care planning (Mcguie 1992).

Michele Habich works for Central DuPage Hospital in Winfield, Illinois, as a Pediatric Clinical Nurse Specialist. Mari Jo Letizia works for the Loyola University Chicago School of Nursing in Chicago, Illinois, as a Professor and Associate Dean. In this article, they conducted an experiment that examined the efficiency of pediatric pain assessment. To investigate this problem, they used an education program and examined the pediatric protocol in a community hospital.

• 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).

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).

And next would be the patient’s family, they would be the secondary audience for my research as they will be the one who can be influential towards the patient if not, they will be the one who are the caregiver of the patient. To me, it is important for both the patient and the family members to be aware of the data, to know and understand the important to patient compliance that will have an impact towards the survival rate of the patient in additional to the quality of life of the patient, especially when it comes with treatments that involves pain management. Last but not the least is to bring awareness to the healthcare providing community regarding the topic and on growing challenges of patient compliance, so the healthcare provider can intervene and improve their communications and their outreach towards their patients and the patient’s

The education strategy developed for this QIP is aimed at ensuring nurses are accurately assessing and documenting pain. The nurses are not being required to learn a brand new skill; rather this strategy is aimed at changing how nurses are completing this task in their practice. Planned change must be a “well thought out and deliberate effort to make something happen” (Marquis & Huston, 2012, p. 163). Therefore, the application of Kotter’s eight-step change model (1995) will help to implement this change.