The Root Cause Analysis Of Rca Essay

S.P. is admitted to the orthopedic ward. She has fallen at home and she has sustained an intracapsular fracture of the hip at the femoral neck. The following history is obtained from her: She is a 75-year-old widow with three children living nearby. Her father died of cancer at age 62; mother died of heart failure at age 79. Her height is 5’3 and weighs 118 pounds. She has a 50 pack year smoking history and denies alcohol use. She has severe Rheumatoid Arthritis (RA) and had an upper GI bleed in 1993 and had Coronary Artery Disease with CABG 9 months ago. Since that time, she has engaged in “very mild exercise at home.” Vital signs are 128/60, 98, 14, 99 degree farenheight (32.7 degrees C) SAO2 94%

As a nurse we want to ensure that our patients receive a high quality of care. Patients should feel safe and satisfied while hospitalized. Many hospitals are continually looking for answers and implementation to significantly reduce the inpatient fall incidents. According to Bechdel et al (2014), the top priority of health care organizations nationwide is to reduce and eliminate falls within the clinical care settings. One of the serious problems in acute care hospital is the patient’s fall. The unfamiliar environment, acute and co-morbid illnesses, prolonged bedrest, polypharmacy, and the placement of tubes and catheters are common challenges that place patients at risk of falling. Most of the falls that I have encountered while working involves

For the most part, hospitals are places where one comes for healing and it is place where our clients should feel safe and away from harm. Nurses have an important role as a patient advocate and are to provide all clients with safe, compassionate, and quality care at all times. Nonetheless, the hospital can also be a dangerous place for inpatients. It is a foreign environment to clients and there may be alterations in their medical condition in regards to their physical and/or mental status. With this said, there is a need to improve upon how we care for our clients, especially those who are at most risk for various incidents.

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.

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.

Kalisch, Beatrice J. PhD, RN, FAAN; Tschannen, Dana PhD, RN; Lee, Kyung Hee MPH, RN (2012). Missed Nursing Care, Staffing, and Patient Falls. Journal of Nursing Care Quality: January/March 2012 - Volume 27 - Issue 1 - p 6–12 doi: 10.1097/NCQ.0b013e318225aa23.

Meanwhile, elsewhere in Habersham County, Tom was feeling slightly nervous as he exited the staff lounge and entered the hustle and bustle of County Hospital’s ER to begin his first shift as an RN. The first few hours of his shift passed slowly as Tom mostly checked vital signs and listened to patients complain about various aches, pains, coughs, and sniffles. He realized that the attending physician, Dr. Greene, who was rather “old school” in general about how he interacted with nursing staff, wanted to start him out slowly. Tom knew, though, that the paramedics could bring in a trauma patient at any time.

With the health care system changing so rapidly, it is important that nurses are autonomous. It is necessary, as patient advocates, that we understand the cause and effect of all entities involving our patients. Critical thinking and making the correct judgment call clinically is vital. A patient situation which comes to mind is an 86 year old female, weighing 50kg, Vital Signs: Blood Pressure: 80/50, Heart Rate: 102 (Sinus Tachycardia), Respirations:

Elliott, M., Page, K., and Worrall-Carter, L. (2012). Reason’s accident causation model: Application to adverse events in acute care. Contemporary Nurse, 43(1), 22-28.

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

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

The objective of this reflection is to explore and reflect upon a situation from a clinical placement on an orthopedic unit. The incident showed that I did not provide safe, timely and competent care for my patient when the oxygen saturation was low. Furthermore, this reflection will include a description of the incident, and I will conclude with explaining what I have learned from the experience and how it will change my future actions.

John was a 76 year old gentleman returning to an orthopaedic ward following a total hip replacement under general anaesthetic. The agreed care plan was to regularly monitor John’s vital signs over the next several hours in accordance with local hospital resuscitation trust policy (2012) and the National Institute

Incident reporting mechanism is an essential component in nursing occupation that facilitates the identification and monitoring of adverse events or incidents that occur during health care service. It is a defined procedures and protocols that should be place and disseminate throughout the organization. The reporting system is used to report occurrence such as falls, safety issues for patients, medication errors, treatment and procedural problems, and malfunctioning equipment. The benefit of incident reporting mechanism is to protect patient from injury or harm. In order to maximize patient safety, adverse events, mistakes and errors, and near misses incidents should be report in a timely and accurate manner. Furthermore, it is also used to make the nurse aware of inadequacies of her own part which make her reflect upon the situation and how this could be learned from, so as to prevent making same mistake again.