A root cause analysis (RCA) is a structured approach of problem solving methods used to reveal the causes of problems or events (American Society for Quality, n.d.). RCA is widely used as an error analysis technique in healthcare to identify underlying systemic problems that increase the likelihood of errors while, at the same time, avoiding the placing of blame on individuals. Here, healthcare patient safety experts use the systems thinking approach to identify both active errors (errors occurring at the point of interface between humans and a complex system), as well as latent errors (the hidden problems within health care systems that contribute to adverse events). The goal of RCA is to prevent future harm by eliminating the latent errors that often underlie adverse events (Agency for Healthcare Research and Quality, 2017, June). For this assignment, you will read the case provided and conduct an RCA. Detailed instructions are provided after the case.
You are the Patient Safety Officer in a 436-bed acute care hospital located in the northeastern part of the United States. You have just returned to your office following a meeting with your leadership team when you are advised of a patient safety incident that has occurred in the Medical-Surgical Unit. The following details are the narrative submitted by the unitâ€™s nurse supervisor via your hospitalâ€™s online incident reporting system.
Friday, April 13, 2018 â€“ 7:46 p.m. Having just come on duty and receiving report from the day shift nurse, the night shift nurse was rounding on her patients when she expressed concerned about one of her patients â€“ Mr. M â€“ who is scheduled for orthopedic surgery the following day. She indicates to the nurse supervisor that â€œMr. Mâ€™s case does not seem as simple as the day shift nurse indicated during her report.â€ This prompted further investigation. The night shift nurseâ€™s report is as follows:
62-year-old, 285-pound male admitted through the emergency department (ED) following a fall at home. Patient stated he heard a loud pop in his left hip. Patient states that the same hip was previously fractured two years ago resulting in compression hip screw placement. Orthopedics saw the patient; x-rays ordered which show an intracapsular fracture (break occurs below the ball or in the neck of the femur) at the site of the previously placed hardware. Morphine pump ordered for pain. Patient placed on low-flow oxygen (4 liters per minute). Surgery planned for following morning. Patientâ€™s medical history documented, preoperative labs ordered, and the consent was signed. Patient is on Coumadin (blood thinners) for a history of blood clots in his lungs that occurred after his previous hip fracture surgery. Chest x-ray: normal. Although Coumadin was suspended for surgery, patientâ€™s blood noted to be mildly thinned. Other past history: significant for emphysema (on home oxygen), hypertension, type II diabetes mellitus, patient still smokes, moderate alcohol consumption. Social history: divorced (10 years), three grown children (all reside out of state), lives alone with therapy dog.
Friday, April 13, 2018 â€“ 8:58 p.m. Night shift nurse checked on Mr. M to find him responsive, but very lethargic. He had been on the unit for about 4 hours. Morphine pump was started upon arrival. Patient denies pain. Vital signs: Heart rate and blood pressure normal, respirations shallow, oxygen saturation at 84% (should be greater than 90%). Respiratory therapy called. Upon arrival, oxygen flow increased to 6 liters per minute; oxygen saturation increased to 93%. Attending physician contacted to report changes in the patientâ€™s condition. Physician indicated that he is not familiar with Mr. M; stated that he was newly assigned to the case when the patient arrived at the ED. He informed the night shift nurse that he thinks that Mr. M â€œgot too much narcotic.â€ Physician placed an order to hold the morphine pump and to â€œkeep an eye on the patient.â€ The night shift nurse placed the patient on a continuous oxygen monitoring (via right index finger) which would notify her if his oxygen level dropped again. The night shift nurse indicated that she felt uneasy about the care plan, but â€œat least the doctor knew what was going on.â€
Saturday, April 14, 2018 â€“ 6:43 a.m. Day shift nurse was preparing to give end-of-shift report at the nurseâ€™s station. Patient care technician rushed out of Mr. Mâ€™s room indicating that she was having difficulty arousing him during morning check of vital signs. Upon entering Mr. Mâ€™s room, day shift nurse finds him unconscious with shallow respirations and elevated heart rate. Code Blue called. Patient intubated, placed on a respirator, and transferred to the Intensive Care Unit (ICU). Surgery cancelled.
From a systems thinking approach, conduct an RCA for this case using the attached Root Cause Analysis and Action Plan grid. For this assignment, you will analyze the sequence of events leading to the error to identify how the event occurred (through identification of active errors) and why the event occurred (through systematic identification and analysis of latent errors). From there, develop an action plan to be put in place to prevent such an event from occurring in the future.
Length: 3â€“4 pages
References: Include a minimum of 3 peer-reviewed, scholarly resources.
Your assignment should demonstrate thoughtful consideration of the ideas and concepts that are presented in the course and provide new thoughts and insights relating directly to this topic. Your assignment should also reflect graduate-level writing and APA standards (6th ed.).
Agency for Healthcare Research and Quality. (2017, June). Root cause analysis. Retrieved from https://psnet.ahrq.gov/primers/primer/10/root-caus…
American Society for Quality. (n.d.). What is root cause analysis (RCA)? Retrieved from http://asq.org/learn-about-quality/root-cause-anal…