Root Cause Analysis Case Study

Review the case at the U.S. Department of Health and Human Services, Agency for Healthcare Quality and Research, “Getting to the Root of The Matter” at https://psnet.ahrq.gov/webmm/case/98/getting-to-the-root-of-the-matter

Prepare a 4-page paper that responds to the following:
1. Define a root cause analysis and when it is used.
2. In the case study identify the incident and explain the problem that might trigger a root cause analysis.
3. Do you agree that the problem should not be investigated? Explain why or why not?
4. Discusses the goals and limitations of root cause analysis;
5. Outline the steps to conduct a root cause analysis.

What is a RCA and when is it Used The acronym RCA is defined as the root cause analysis, which is performed
in the case of a sentinel event. The results of RCA are performed with several clinical trials in the healthcare setting. These trials are done to analyze the errors, and provide solutions to reduce the occurrence of repeating the same errors in the future. Consequently, common sentinel events occur on a regular basis in the healthcare hospital setting. According to S. Flanders, 2015, a very common sentinel event is performing surgery on the wrong site. An example would be performing a TKA (total knee Arthroplasty) on the left knee and the surgery was intended for the right knee. However, irresponsible it may seem it happens frequent in hospital settings where there is chaos. An overworked staff member could make a transcription area on the surgical document thus resulting in a sentinel event. The RCA should be performed on a regular basis to make sure staff is being adequately train, and are abreast on the clinical protocols for all surgical procedures to ensure the patient’s safety. It is important that the safety protocols to prevent sentinel events are inspired by the healthcare professional that will actually be providing the service and not the manager that only delegates.
Identify the Incident and explain the Problem that Might Trigger a RCA A serious incident identified was overdose of medication to the patient, which led to a fatal overdose. The problem that led to this fatal incident was probably the result of inadequate staffing resulting in fatigue of the staff. Consequently, it has been determined that in most cases of reporting of errors, fatigue plays a major role. I have worked in the healthcare field for over 30 years, and have seen changes that put the safety of the patient at risk. The healthcare arena is always looking to increase their profits and decrease their cost expenditure. Consequently, when the hospital settings and skilled nursing facility changed the nursing work schedules it increased medication errors. Conversely, most hospital provided the option of 3- 12 hour shift per week for full-time benefits. A nurse could work 3 days for 12 hours, and get the equivalent 40 hour/week benefits. However, this may seem like a great benefit for the nurse, but not necessarily for the patient. Consequently, if the 3 days are in arrow for the 12 hour shifts this could be very demanding physically on one’s body. This fatigue could result in a sentinel event both for the patient and the healthcare professional. Hence fore, getting the proper rest is very import to the healthcare professional, because someone’s life is in your hands.
Should the Problem be Investigate?
Whenever there is a problem, error, or sentinel event in a hospital or skilled nursing facility it should be investigated. The only way to correct a problem is to explore how the event occurred, and what could be done different to avoid future incidents. Consequently, to ignore the occurrence of the error or problem is a formula to repeat the incident. It is very essential to report all incidents that occur. Incident reporting acts as a deterrent for any future incidents. Most reportable incidents are the incidents that resulted in serious repercussion for the patients, and in some cases even death. According to, Pronovost, 2013, states incident reporting should be reported directly to the governing bodies not in the medical records. Consequently, how incidents are handled will vary by the laws of the State you reside in. In reporting of serious incidents, some States may require the incident report being accompanied by the RCA report. Since April 2007, it became mandatory by the Government Accountability Office that all healthcare- associated infections in hospitals were to be reported. As a result of this mandate, over 27 States had hospitals to report serious incidents or sentinel events.
What are the Goals and Limitations of the RCA?
The governing bodies of hospitals and healthcare facilities have specific goals and limitations that are allowable with the RCA.Consequently, at the national level the Patient Safety and Quality Improvement Act formed in January 2009 collaborates with the healthcare facility in reporting of the RCA.
This organization became known as the Patient Safety Organizations (PSOs), and they determine the safety information that is disclosed pertaining to the patient. Consequently, in 1995 the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), was formed to be the surveillance of healthcare quality control. Initially, the JCAHO encouraged reporting of sentinel events but it was not a requirement. Hence fore, today they have a Sentinel Event Database, which healthcare facility can access to perform voluntary reports of sentinel events. This databased was developed to report serious incidents such as death, loss of function, or loss of
limbs.
Outline the Steps to Conduct a RCA
The first process of the steps to reporting a RCA is that proper reporting of the sentinel event was initiated to the proper governing bodies. The JCAHO mandated that all accredited hospital perform RCA for all sentinel occurrences. The first step is to perform system analyses of the work environment that the sentinel event occurred. Consequently, the work environment is scanned for opportunities to have mitigated the occurrence. This process may consist of performing the flow of events as well as interviewing staff associated with the event. The next step is to carefully review the incident report looking for any deviation in the occurrence given verbally from the staff. The RCA will checked to see if the verbal or written orders were performed to healthcare provide. In the event of medication error, the RCA is able to verify the order in the computerized physician order entry system (CPOE), as a cross reference of validation. The next step is to evaluate the staff’s training skills to perform the successful task. After determing the healthcare provider skills, the RCA will assess if they followed the correct protocol. Consequently, if the correct protocol was followed, then the RCA will focus on other possible contributing factor for the sentinel event occurrence. Hence foe, some contributing factors could have been poor lighting, inadequate staff, fatigued staff, equipment sterilization, and a plethora of other scenarios. The final step in reporting a RCA is the solution to prevent the sentinel event of occurring in the future.

Reference-Module 2
Advancing Patient Safety through State Reporting Systems June 2007 Agency for Healthcare Research and Quality http://webmm.ahrq.gov/perspective.aspx?perspectiveID=43#ref1
Voluntary Patient Safety Event Reporting (Incident Reporting).
U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality; Patient Safety Primers. http://www.psnet.ahrq.gov/primer.aspx?primerID=13
Patient Safety. Minnesota Department of Health Web site. Available at: http://www.health.state.mn.us/patientsafety/ae/index.html
Rule R380-200. Patient Safety Sentinel Event Reporting. The Utah Administrative Code. (March 2013) Patient Safety Initiatives. Utah Department of Health Web site. Available at: http://www.rules.utah.gov/publicat/code/r380/r380-200.htm
Root Cause Analysis. Agency for Healthcare Research and Quality. October 2012 http://www.psnet.ahrq.gov/primer.aspx?primerID=10
Joint Commission for the Accreditation of Healthcare Organizations' " Sentinel Events” – January 2011" found at http://www.jointcommission.org/assets/1/6/2011_CAMLTC_SE_(2).pdf
Patient Safety States. National Academy for State Health Policy
http://www.nashp.org/pst-map