Root Cause Analysis And Rca

Perrow discussed how some accidents are not avoidable. The premise of unavoidability is the basis of the normal accident theory (Hopkins, 2014). The health care industry is subject to regulations by The Joint Commission and Centers for Medicare and Medicaid (Center for Medicare and Medicaid [CMS], 2013). Within complex systems such as health care, training on patient safety is of the utmost importance (Lukewich et al., 2015). As noted by Lukewich et al. (2015), without training and regulations of the healthcare industry, healthcare practitioners make mistakes and accidents happen. Concerning normal accident theory, the theory premise is that some accidents are not avoidable; however, patient safety is an expectation in the healthcare environment (Chowdhury & Habib, 2015). If healthcare staff receive training to reduce inefficiencies, mistakes are less likely to happen (Aebersold & Tschannen,

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 first step of the analysis is to collect data which will help with the understanding of the events. Identifying what data to collect and how and what to compare the results can be challenging. The organization should have a baseline to compare to see how the changes are working. Comparing information to similar organizations through benchmarking may indicate the success of the organization or program. Ransom, Joshi, Nash and Ransom (2008) state “benchmarking compares processes and success through gap analysis, process variation & organizational opportunities for improvement” (pg. 132). Data can be collected from prior litigations and claims information. Monitoring the information through monthly reports can indicate if process modifications or changes are needed. Once information is identified immediate action should be taken to ensure patient safety and minimize risk.

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 root cause analysis is defined as, “a process for identifying the basic or causal factors that underlies variation in performance, including the occurrence or possible occurrence of a sentinel event” (Cherry & Jacob, 2011, p. 442). Involved participants, in the case, the emergency room physician, registered nurse, and licensed practical nurse present during the sentinel event, as well as the emergency room nurse manager, and Chief Nursing Officer, should meet to discuss the events leading up to the patient’s (Mr. B’s) death and establish a root cause analysis. They should explore all hazards and errors in Mr. B’s care. Data should be gathered, facts surrounding the death analyzed, and causative factors should be explored to establish

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).

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).

Inadequate policies and protocols. For example, failure in the process of care can be traced to poorly documented, not-existing procedures. It indicates a lack of an organizational commitment to patient safety.

The Health Care Industry is complex and is responsible for the health of the country (The Hospital & Healthsystem Association of Pennsylvania; Outcome Engineering, 2010), and ultimately of the world. Unfortunately, according to the Institute of Medicine's comprehensive report, "To Err Is Human," avoidable medical errors annually kill 44,000 - 98,000 hospital patients (Reiling, Knutzen, & Stoecklein, 2003). In addition, as of March 31, 2010, the ten most frequently reported sentinel events within U.S. healthcare organizations are: "wrong site surgery; suicide; operative/post-operative complication; delay in treatment; medical error; patient fall; unintended retention of a foreign body; assault, rape or homicide; perinatal death or loss of function; patient death or injury in restraints" (HealthLeaders Media, 2010). Clearly, many of these

Preventable adverse events or sentinel events are defined as events that cause an injury to a patient as a result of medical intervention or inaction on the part of the healthcare provider whereby the injury cannot reasonably be said to be related to the patient's underlying medical condition (California Healthcare Foundation (CHCF), 2001). VHS has documentations, forms and processes laid to address occurrences of any preventable adverse events. The first step is conducting the Root Cause Analysis. In order to scrutinize and evaluate adverse events that lead to health injury or death, a Root Cause Analysis can be used as part of the Risk Resiliency method to investigate causal relationships of various factors that can ultimately

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

As the patient safety officer, I am involved in the frequent root cause analysis (RCA) that result in improvements due to a retrospective response to specific events. Likewise, I am involved in many patient safety and quality initiatives where information from occurrences is used to improve quality, such as the falls prevention program, hospital-acquired pressure ulcer prevention, medication safety to name a few. These are broader approaches for improvement using a collaborative, multidisciplinary effort directed at improving the quality throughout the organization rather than a specific reaction

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).

Using a root cause analysis to brainstorm and figure out why things are the way they are or are not the way they should be helps identify the problem at hand. For example in the Clemson article, a root cause analysis was done to find

A personal conflict that I have recently encountered was among one of my roommates and the rest of our household. Currently I live with four other individuals. We all have our own bedrooms and our own space so it is possible that we have our own places to go when our living situation tends to be a little too much around the house. Now our schedules are all different, so we are not all home at the same time, which can be both a positive thing and a negative thing. Now, one of our favorite restaurants to venture to is a local traditional sushi and hibachi restaurant in the area. One of our roommates, Travis, he is especially fond of this restaurant. The specific conflict that we have recently encountered can be best summed up as the four of