Healthcare Root Cause Analysis Essay
Healthcare Root Cause Analysis Essay
Nowadays, the primary goals of health care are quality improvement and patient safety. To support medical professionals in performing their work, it is crucial to evaluate potential errors and investigate the imperfections of the system. Root cause analysis (RCA) is regarded as a key tool to determine underlying issues that led to the problem and the changes required to avoid it.
The RCA team of the reviewed case scenario consists of the nurse manager, the director of a pharmacy, and the facilitator, who is a quality assurance person. Healthcare Root Cause Analysis Essay. Each member of the team contributes specific knowledge to the root cause analysis. The nurse provides information about her work, emphasizing the difficulties with scanning the medication’s labels, and reaching a pharmacist. The pharmacist shares difficulties in his work that may cause a burnout error and mentions a lack of knowledge. The facilitator helps them to avoid blaming and focus on identifying the root causes of the error, which is administrating an incorrect medication to the patient.
Some researchers state that “RCAs are typically time-consuming and labor-intensive with a primary goal of producing a report” (Li et al., 2015, p. 495). The case scenario shows that the process might become exhausting even for the participants who are trained to manage root cause analysis. In the case scenario, the collaboration included a description of the difficulties in the work of the nurse and the pharmacist that might lead to a medication error.
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It helped the parties to come to the effective solving of the problem. The evidence of effective collaboration is presented in the cause-effect diagram that was produced in the process of the root cause analysis. The diagram shows the bottlenecks of staff and equipment performance. Spath (2013) states that “performance assessment involves judging or evaluating measurement data for the purpose of reaching a conclusion” (p. 65). The diagram shows the data collected during the process of problem discussion. Some of the causes are believed to be bad equipment, defective barcode labels, and the scanner failing to process the delivered medication. The human factors were taken into account as well. Healthcare Root Cause Analysis Essay.
After the identification of performance problems, the causes of insufficient performance should be identified. The team’s process of testing and eliminating the root causes that are not contributing to the problem included identifying the percentage of medication errors for each cause, assessing the risks of its occurrence. Usually, organizations have limited resources, money, and time for improvement projects, and the team has to identify the most crucial issues.
According to Yoder-Wise (2015), “the impact of organization-wide change depends on the organization’s particular stage of development, degree of flexibility, and history of response to change” (p. 326). One of the performance improvement charts presented in the scenario is the Pareto chart of medication error analysis. It helps to identify the root cause assessing the percentage of medical errors for each cause and select the most crucial ones by the high percentage of their occurrence. It also helps to determine the solution to prevent repetitive medical errors by distinguishing the root causes that can be eliminated.
According to the process of testing and eliminating root causes, human factors and lack of pharmacy round were recognized to be the most serious contributing factors of medical errors. Drug administration errors may have serious consequences for the patient. Healthcare Root Cause Analysis Essay. Some researchers advise using Lean Six Sigma methods to improve the efficiency of drug round and prevent such errors. It is noted that “the application of LSS principles enables identification and removal of waste to add value to the patient” (Kieran, Cleary, De Brún, & Igoe, 2017, p. 2). To avoid human factors, it is advised to encourage cell phone communication at the hospital territory.
The reviewed case scenario dealt with the root causes analysis of the problem dealing with the supply of proper medications from the pharmacy, which caused medication errors. The members of the RCA team managed to come to the agreement that the main cause of the problem is the lack of pharmacy rounds. Specific decisions were suggested to prevent medication errors in the future.
References
Kieran, M., Cleary, M., De Brún, A., & Igoe, A. (2017). Supply and demand: Application of Lean Six Sigma methods to improve drug round efficiency and release nursing time. International Journal for Quality in Health Care, 29(6), 803-809.
Li, J., Boulanger, B., Norton, J., Yates, A., Swartz, C. H., Smith, A., & Williams, M. V. (2015). “SWARMing” to improve patient care: A novel approach to root cause analysis. The Joint Commission Journal on Quality and Patient Safety, 41(11), 494-500.
Spath, P. (2013). Introduction to healthcare quality management (2nd ed.). Chicago, IL: Health Administration Press.
Yoder-Wise, P. S. (2015). Leading and managing in nursing (6th ed.). St. Louis, MO: Mosby. Healthcare Root Cause Analysis Essay.
As a solution, core staffing should consist of at least two registered nurses, an ED physician, and secretary on duty at all times, with a plan for increases based on current census and acuity, nursing time and interventions, length of stay, skill mix and patient care time (Emergency Nurses Association, 2011). By having this core staff in place, the patient would have had a nurse available to continuously monitor his status. Neither staff member identified the downward trending of the patients available vital signs and did not evaluate consciousness of the patient. Failure to assess appropriately and recognize deterioration of the patient resulted in a prolonged period of time in which the patient was not adequately oxygenated. Research has shown that short staffing, with decreased nurse to patient ratio, has been found to be associated with increased mortality (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Joint Commission on Accreditation of Healthcare Organizations, 2005; Needleman, Buerhaus, PKankratz, Leibson, Stevens, & Harris, 2011). Healthcare Root Cause Analysis Essay. This reinforces the need to match staffing with patient census, acuity, and need for nursing care. A policy for conscious sedation was in place and not followed by staff. As all staff had been trained in the procedure, completed the appropriate modules, and
The patient was resuscitated and intubated and sent to the ICU. Seven days later the patient was declared brain dead and expired after the removal of life support. To prevent this scenario from happening again many things can occur. Benchmarking to assess for adequate staffing needs during high volume times in the emergency department. Implement a process to fill staffing needs in these times of high volume. Also educating the staff on conscious sedation protocol and medication administration for patient populations related to age, comorbidities and current medication regimen. Monitoring the use of policies and procedures to make sure that they are being followed and remain safe for the patient.
Errors in the Care In the care of Mr. B the following errors occurred:
The patient was not placed on the ECG monitor
He was not placed on any supplemental oxygen
There was no staff in the room monitoring the patient while still under conscious sedation
The LPN resets the alarm on the oxygen monitor and leaves the room without reporting it to anyone.
Not having adequate staffing for the high acuity of patients in the Emergency Department The nurse should have contacted the nursing supervisor to ask for a person certified to do conscious sedation to come and monitor the patient. This alone would have prevented many of the other errors that occurred. The patient would have been placed on the monitor and oxygen would have been delivered prior to . Healthcare Root Cause Analysis Essay.
