Root Cause Analysis Paper

hospital, which shows that there was clearly a lack of quality care being provided and that there was something that was

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

One of the most critical factors which contribute to the number of preventable cases of healthcare harm is the culture of silence surrounding these cases. The fear of medical providers to report incidences is related to the possibility of punishment and liability due to a medical error (Discovery, 2010). The criminalization of some acts of medical error has resulted in job dismissal, criminal charges and jail time for some healthcare workers. This is despite the fact that the system they are working in helped to create the situation which led to the error in the first place. Human error, due to fatigue and system errors can result in deadly consequences, but by criminalizing the error it effectively shuts down the ability to correct the root problem. Healthcare workers, working at all levels within the medical system, can provide valuable input on how to improve the processes and prevent harm from occurring (Discovery, 2010).

Willow Bend Hospital’s compliance does indeed have multiple deficiencies and is in need of review as many were updated in 2009 and 2010. All information on deficiencies would be found on the latest updated version of the Joint Commission Information Standards. This should be located within the Corporate Compliance/Risk Manager’s office. As this information is not currently available to this writer without a subscription and fee, I must use the information available to me. So expansion and explanation of policy details are limited.

We know that he had sustained an at home fall. We learn that he has a history of pain and a prescription for oxycodone for back pain. We know that his vital signs on admission appear stable; he was not showing any signs of respiratory distress. As we look at the staff that was listed that day we do get the sense the hospital may have been short staffed. Staffing report shows there was one MD, one RN and one LPN managing at least 4 patients including- one patient was a child. Evidence based research has proven that the nurse to patient ratio is directly related to the patient outcomes (Stanton, 2004). It is important that we consider the staffing level that this rural ED as we know short staffing can be blamed for not being able to take the full amount of time needed to do a proper health history. A detailed health history is an imperative part of the care process; it is used by the staff to accurately assess any acute changes that may take place in the patient throughout their stay.

To do so, I am going to use the fishbone diagram to categorize the causative factors (Potter & Perry, 2008).   For patient characteristics, Mr. B was a 67 year old patient with routine use of oxycodone to treat chronic pain.  Because of his routine use of oxycodone, he may need a different dose to get to a sedated level than other people who are not on any medication.  Next is the task factors, the hospital had a policy which requires that anyone who are treated with moderate sedation or analgesia have to be put on continuous blood pressure, ECG, and pulse oximeter monitoring until the procedure is done and patient is in stable condition.  Mr. B was not being monitored accordingly during the sedation process.  Another task factors is that all staffs must first complete a training module on sedation before performing the task.  Individual staff is a factor too, Nurse J had completed the training module on sedation, he had an ACLS certification as well as experience working as a critical care nurse.  Team factors include communication between staffs; an example would be the LPN not informing Nurse J or Dr. T when the alarm went off the first time, it showed that Mr. B had low oxygen saturation.  Work environment factors included the staffing in the ER, the equipments they had, and the level of experience of the staffs.  According to the scenario, additional staffs were available for back up support and all the equipment needed

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

A root cause analysis (RCA) is an essential tool that can be used to examine and understand the ways in which systems fail as well as discuss those specific failures that led to a specific adverse event and potentially implement steps or behaviors to prevent that event from happening in the future (Ogrinc & Huber, 2013). In the case study presented, a number of system failures may have contributed to the patient outcome. As such, an RCA of the case study would help determine those specific

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.

A physician could make mistakes in prescribing, the pharmacy could send the wrong medication, but who actually gave it to the patient is accountable for the consequences. For this reason, it’s our responsibility to implement change in our practice based on the evidence in order to ensure safe patient care.

I usually have a problem with people who the relation with them is normal because they misunderstand me most of the time, they got started annoying me in many occasions, once I was driving a car passed the roads and didn't greet them, after a while, I surprised they talked to me, directly why you did not say hello that time when you was driving a car, you have to say that, not only you who have a car. I immediately answered, during driving a car I don't to lose my concentration on the road and maximize the probability of the accident, just to say hello, and you are able to mention your notes politely, not in the harsh way.

After each question, he would write my response on a card and place it on his desk in sequential order.

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).

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.

In this essay I will examine how Waikato DHB responds when a patient suffers an “adverse event”. An adverse event can be defined as an incident during the course of medical treatment or care, which results in harm to a patient or service user. Examples of adverse events can include: falls in hospital, serious medication errors, healthcare associated infections, wrong diagnoses or delays in diagnoses, wrong procedure/wrong patient,