Examples Of Root Cause Analysis
Root Cause Analysis.
Root cause analysis is an effective tool used in many industries, including healthcare, to establish a key reason that an outcome, that was not as anticipated, did in fact happen. In other words, what was the crucial reason for a specific outcome (Bohannan, 2016). Root Cause Analysis (RCA) is not a blaming activity but put in place for improving patient care. This may sound simple, but it is not as simple as it appears. There can be many causative factors throughout the many departments that are used in healthcare and it is possible that there could be more than one causative factor involved, but not necessarily the most obvious one. To have a positive outcome from a process that has failed our patient’s population in some way, whether it be a sentinel event or a less tragic outcome, it is necessary to change the process. To recognize that there are errors in the system, it is necessary to …show more content…
The patient arrived at the ED with (L) hip pain, it was determined that the hip needed reduction. Due to the patient using Oxycodone for chronic back pain, he appeared to need more of the medication to sedate the patient. The patient eventually had the hip reduction. The patient was not put on supplemental oxygen, which was supposed to be used per the moderate sedation. Also per the protocol, the patient should have continuous B/P, respiratory and ECG monitoring.
Due to an emergent respiratory case arriving, the patient was left with son, rather than with an RN. Oxygen saturation (SpO2) continues to drop to 85%; LPN resets the SpO2 alarm and takes patient’s blood pressure.
Blood pressure and SpO2 drop even further to 58/30 and 79% respectively; there is no palpable pulse. A code is called, when the monitor is connected the patient is in VF. CPR, IVS, medications and intubation are initiated. The patient is not responding to stimuli, pupils are fixed and dilated. Patient was taken by air transport to a tertiary
Root cause analysis is an effective tool used in many industries, including healthcare, to establish a key reason that an outcome, that was not as anticipated, did in fact happen. In other words, what was the crucial reason for a specific outcome (Bohannan, 2016). Root Cause Analysis (RCA) is not a blaming activity but put in place for improving patient care. This may sound simple, but it is not as simple as it appears. There can be many causative factors throughout the many departments that are used in healthcare and it is possible that there could be more than one causative factor involved, but not necessarily the most obvious one. To have a positive outcome from a process that has failed our patient’s population in some way, whether it be a sentinel event or a less tragic outcome, it is necessary to change the process. To recognize that there are errors in the system, it is necessary to …show more content…
The patient arrived at the ED with (L) hip pain, it was determined that the hip needed reduction. Due to the patient using Oxycodone for chronic back pain, he appeared to need more of the medication to sedate the patient. The patient eventually had the hip reduction. The patient was not put on supplemental oxygen, which was supposed to be used per the moderate sedation. Also per the protocol, the patient should have continuous B/P, respiratory and ECG monitoring.
Due to an emergent respiratory case arriving, the patient was left with son, rather than with an RN. Oxygen saturation (SpO2) continues to drop to 85%; LPN resets the SpO2 alarm and takes patient’s blood pressure.
Blood pressure and SpO2 drop even further to 58/30 and 79% respectively; there is no palpable pulse. A code is called, when the monitor is connected the patient is in VF. CPR, IVS, medications and intubation are initiated. The patient is not responding to stimuli, pupils are fixed and dilated. Patient was taken by air transport to a tertiary