Root Cause Analysis : Root Causes Analysis

Environmental Factors: The hospital is a very busy place. The background noise can distract the attention of the physicians while they ponder over the right prescription of a drug. The high demand of a medical profession can be stressful and lead to fatigue. These possible occupational hazards can contribute to medical errors.

S.P. is admitted to the orthopedic ward. She has fallen at home and she has sustained an intracapsular fracture of the hip at the femoral neck. The following history is obtained from her: She is a 75-year-old widow with three children living nearby. Her father died of cancer at age 62; mother died of heart failure at age 79. Her height is 5’3 and weighs 118 pounds. She has a 50 pack year smoking history and denies alcohol use. She has severe Rheumatoid Arthritis (RA) and had an upper GI bleed in 1993 and had Coronary Artery Disease with CABG 9 months ago. Since that time, she has engaged in “very mild exercise at home.” Vital signs are 128/60, 98, 14, 99 degree farenheight (32.7 degrees C) SAO2 94%

Root Cause Analysis (RCA) is a controlled method used to analyze serious adverse events. Originally developed to analyze industrial accidents, RCA is now commonly organized as an error investigation tool in health care. A principal theory of RCA is to identify fundamental problems that increase the probability of errors while avoiding the trap of focusing on mistakes by individuals. RCA thus uses the systems approach to identify both active errors: errors occurring at the point of interface between humans and a complex system and dormant errors: the hidden problems within health care systems that contribute to adverse events. It is one of the most widely used methods for detecting safety

Nightingale Community Hospital identified a recent sentinel event involving the ambulatory surgical center. A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (http://www.jointcommission.org/sentinel_event). A three year old female presented to the hospital on September 14th for a planned outpatient procedure. The child was accompanied by her mother. The mother registered the patient with the registrar prior to the procedure. The patient and her mother went to the pre-operative area to complete the informed consent and the necessary physical assessment. The pre-operative nurse obtained the necessary contact

Root Cause Analysis (RCA) is a popular and often-used technique that helps people answer the question of why a problem occurred in the first place. Healthcare, in my opinion, is an area where this approach is very important and crucial to implement since it helps determine what and why something happened as well as figuring out what to do to reduce the likelihood of it reoccurring. I personally never knew anything about RCA but now that I do it is a very crucial practice to implement since it can show results. RCA assumes all systems are interrelated so by tracking back actions you can discover where the problem started and how it grew into the symptoms you are now facing. None the less this is a very important tool since it is able to find the hidden flaws in the system and

This paper will analyze the cause of the sentinel event which occurred to Mr. B, a sixty seven year old patient which presented to the emergency room with left leg pain. A root cause analysis will be necessary in this case to investigate the causative factors which led to Mr. B’s sentinel event. The factors in this unfortunate case weather they were errors in his care, or hazards in the system will be identified. The Change theory will be used to develop an improvement plan that will be used to decrease the chances of a reoccurrence of the sentinel event that happened to Mr. B. in the scenario.

The goal of this paper is to scrutinize the regrettable sentinel event of Mr. B, a sixty-seven-year-old patient who was admitted to a rural ED with left leg pain that he found unbearable. A root cause analysis will be used to exam the causative factors that led to this unfortunate sentinel event. Then I will identify the errors or hazards in the care of Mr. B. A change theory will then be utilized to establish a useful improvement plan that would hopefully decrease the chances of a repeat of the outcome in the Mr. B scenario.  A Failure Modes and Effects Analysis (FMEA) will then be

3) Surgeon: Was directly involved in the events leading up to the sentinel event. The surgeon was responsible for all activities taking place in the surgical suite and directly related to the surgery of the pediatric patient. The surgery was completed safely and successfully; however, the surgeon had relevant information in the patient chart at his office yet did not share this information with the hospital. He also did not supply an appropriate or accurate H&P that would have included custodial status for the pediatric patient to the hospital. The surgeon is greatly concerned in the events that lead to the sentinel event and wants to ensure that his patients will be cared for and safe at Nightingale Community Hospital.

A root cause analysis (RCA) is a method by which we can examine a serious adverse event and identify the cause, or causes, that led up to the event. Although personnel are involved in these events, the primary purpose of the RCA is to identify the cause, not to assign blame (Agency for Healthcare Research and Quality, 2014). It is through identifying a cause, or causes, of an adverse event that we can improve on patient care processes and thereby patient safety. The RCA is designed as a specific protocol that starts with data collection looking at the sequence of events that led to the

A root cause analysis (RCA) is an essential tool that can be used to examine and understand the ways in which systems fail as well as discuss those specific failures that led to a specific adverse event and potentially implement steps or behaviors to prevent that event from happening in the future (Ogrinc & Huber, 2013). In the case study presented, a number of system failures may have contributed to the patient outcome. As such, an RCA of the case study would help determine those specific

The purpose of this paper is to analyze the unfortunate sentinel event of Mr. B, a sixty-seven-year-old patient presenting with severe left leg pain at the emergency room. A root cause analysis is necessary to investigate the causative factors that led to the sentinel event. The errors or hazards in care in the Mr. B scenario will be identified. Change theory will be utilized to develop an appropriate improvement plan to decrease the likelihood of a reoccurrence of the outcome of the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA) will be used to project the likelihood that the suggested improvement plan would not fail. Lastly, key roles nurses would play in improving the quality of care

The scenario was alarming yet gave a realistic view on how non-adherence of procedure, breakdown of communication and the lack of accountability became the triggers for this sentinel event. Since 1996 the Joint Commission as instituted a sentinel event policy that enables hospitals to evaluate and implement corrective action that will reduce future risk (Sentinel Event Policy and Procedures, 2014). My role as the medical student was significant to the outcome because I was medical aware of abnormal changes however not confident enough in my abilities to be an advocate for the patient. Evidence of the patient status through data trending would have provided the support I need to contact the attending physician. The inability to follow proper hospital procedure related to aseptic techniques was the first of many problems.

first step in conducting a root cause analysis is to form a committee of individuals that are from

Incident reporting is important to understand so that the health and safety of the abused or injured is preserved and the acts are stopped. Incident reports are different in every facility and this document goes to the person responsible for investigating the incident and not in the chart. Failing to report can end in civil and/or criminal charges with monetary retribution attached. Sentinel events are important to understand so that the Joint Commission or other governing entity knows about the event so that it can be stopped, investigated or changes can be made so that the event does not happen again or to anyone else. Root cause analysis is the underlying cause of the event, the processes of the event from beginning to the end so that overall

A personal conflict that I have recently encountered was among one of my roommates and the rest of our household. Currently I live with four other individuals. We all have our own bedrooms and our own space so it is possible that we have our own places to go when our living situation tends to be a little too much around the house. Now our schedules are all different, so we are not all home at the same time, which can be both a positive thing and a negative thing. Now, one of our favorite restaurants to venture to is a local traditional sushi and hibachi restaurant in the area. One of our roommates, Travis, he is especially fond of this restaurant. The specific conflict that we have recently encountered can be best summed up as the four of