Question

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HeHealth Care Organizations Professional Practice Standards

JC Tool to Assist Organizations in the Completion of the
Framework for Conducting a Root Cause Analysis (edited)

Please note that the root cause analysis and action plan must show evidence of an analysis within the key components as outlined on the root cause analysis matrix for the specific type of event. An area on the matrix that may not have an identified process breakdown should still be summarized to determine that the component was evaluated. Below are Example of how write these Root Cause Analysis Paper.

• Brief description of event

Briefly summarize the circumstances surrounding the occurrence including the patient outcome (eg, death, loss of function).

Example: A thirty-six-year-old male admitted for left hernia repair on May 3, 2002. A right hernia incision was made when the surgeon realized the left side was to be performed. The right side was closed, and the left hernia repair was completed.

• What area/service was impacted?

Include the full variety of services impacted by the event.

Example: This might include Operating Room, Nursing, Medical Staff, Recovery Room, and Preadmission Testing.

• What are the steps in the process, as designed?

List the key steps involved in the specific processes relating to the event.

      Example: For wrong site surgery you may list specific steps within key processes such as       Preadmission Assessment and Verification of Site, Site Verification and Assessment by Surgeon,       Preanesthesia Assessment, Surgical Preparation and Verification of Site, etc.

Answer 1

Root cause analysis is part of a more general problem-solving process and an integral part of continuous improvement. Because of this, root cause analysis is one of the core building blocks in an organization’s continuous improvement efforts. It's important to note that root cause analysis in itself will not produce any results. It must be made part of a larger problem-solving effort for quality improvement.

In health care, field Root Cause Analysis (RCA) is a structured method used to analyze serious adverse events. or

Root cause analysis is a process for identifying the basic or causal factor(s) underlying variation in performance. Variation in performance can (and often does) produce unexpected and undesired adverse outcomes, including the occurrence or risk of a sentinel event.

A root cause is the most fundamental reason (or one of several fundamental reasons) a failure, or a situation in which performance does not meet expectations, has occurred.

*Brief description of the event

An 18-year-old patient came to the hospital for delivery. During the procedure, an infusion that is prepared for the epidural route was connected to the patient’s peripheral intravenous line and started infusion by the pump. The patient experienced cardiovascular collapse. A cesarean section resulted in the delivery of a healthy infant, but the medical team was unable to resuscitate the mother. The media attention surrounding the error accelerated through the national provider and safety community when the nurse was charged with a criminal offense.

-These events set in motion intense internal and external scrutiny of the hospital’s medication and safety procedures. To further understanding about latent systems gaps and process failure modes, a root cause analysis of the event was conducted.

-A team conducted a one-week evaluation of the medication use system and the organization’s current environment, systems and processes, staffing patterns, leadership, and culture to help shape the recommended improvements.

-For each of the four proximate causes of the event, performance-shaping factors were identified. Although the hospital’s organizational learning was painful, this event offered an opportunity for increasing organizational competency and capacity for designing and implementing patient safety.

-Structures and processes, including safety nets and fail-safe mechanisms, were implemented to promote safer behavioral choices for providers.

The hospital took a number of clinical steps to improve the safety of medication administration, including removing the barriers to scanning medication bar codes, implementing consistent scanning-compliance tracking, and providing teamwork training for all nursing and physician staff practicing in the birth suites.