Root Cause Analysis
For accreditation purposes, healthcare organizations like the Joint Commission require that healthcare institutions have a systematic process of analyzing sentinel events. The Root Cause Analysis (RCA) is one of the processes that intend to investigate sentinel events to allow optimization of care (Driesen et al., 2022). RCA is a method used to investigate an incident in order to assist in the identification of system failures that may not be easily identified during the initial review. This process seeks to determine what happened, why it happened, and how it can be prevented from occurring again. During the RCA process, the investigators are tasked with identifying issues that contributed to the sentinel event and providing recommendations on actions that can be implemented to minimize the occurrence of similar incidents (Driesen et al., 2022). The RCA process is also used to protect patients by identifying challenging factors that can harm patients within the healthcare institution.
A1. RCA Steps
Root cause analysis is a process widely adopted by healthcare organizations to learn how errors occur and measures to rectify these errors. The Institute for Healthcare Improvement (IHI) identifies six steps that can be adopted by healthcare organizations when conducting RCA.
Step I: Identify what happened
Step II: Determine what should have happened
Step III: Determine causes
Step IV: Develop causal statements
Step V: Generate a list of actions to prevent recurrence of the event
Step VI: Share the findings
The first step is to identify what happened and it serves to clarify the problem and its scope. The selected team for investigating the incident begins by identifying who was involved, what exactly happened, where it happened, changes to practice guidelines observed, the consequences of the event, and why it happened. The most important thing during this step involves taking time to create a solid ground or develop a solid argument concerning the sentinel event (Institute for Healthcare Improvement (IHI), n.d.). The success of this step ensures that team members share a common understanding of the problem.
Step two of the RCA process involves finding the causes of the observed sentinel event by determining what should have happened. The goal of this step is to uncover as many reasons as possible to explain observed outcomes (IHI, n.d.). For example, clinical practice guidelines should be reviewed to determine aspects that were wrongly done by the healthcare team. To help gather accurate information, the team uses approaches like brainstorming, process mapping, and Fishbone diagrams. The use of these tools helps in improving creativity and ensures the team covers all the possible reasons that contributed to the adverse outcome.
The third step involves harmonizing the findings to come up with the root cause of the adverse outcome. This step requires the organization of information and events as they happened during the build-up of the sentinel event. The team should seek explanations from the teams involved and use triggering questions to guide further investigation. The five whys strategy is among the best methods that are proposed to elicit the right response during this step (IHI, n.d.). The main goal is to determine the root cause of a problem by successively asking the question why to each response given. In complex healthcare issues, the RCA team can use other tools like histograms, scatter charts, or Pareto analysis to come up with the most precise reason an event happened.
Step four of the RCA process involves developing causal statements to explain why the sentinel event occurred. The team should identify gaps in care delivery that led to the adverse outcome to guide decision-making (IHI, n.d.). Causal statements are important because they help to generate links between patient care and the actions of the healthcare team that led to the main problem.
Step five of the RCA process involves finding solutions to the observed problem by generating a list of actions that can prevent recurrence of the event. Brainstorming is a very important approach in a team environment to identify potential solutions to the healthcare problem (IHI, n.d.). Another key strategy is to use flow charts and the why not process to identify specific points that can be changed to effectively prevent future occurrence of the observed problem. Because of the multiple causes of sentinel events, multiple solutions may be available to address the root cause of the event.
The sixth step of the RCA process is to communicate findings to the healthcare providers and take action to avoid the occurrence of another adverse outcome. The healthcare providers should be informed about the root cause of the problem, practice guidelines that were not followed, and proposed solutions to the identified problem. During this step, the RCA team may implement the changes and use tools like the Force Field Analysis to determine the impact of the new change on the patients and the healthcare organization (IHI, n.d.). Additionally, it is crucial for the team to be patient and take time to observe the changes before concluding that the problem was resolved.
A2. Causative and Contributing Factors
The presented case involves Mr. B, a 67-year-old patient brought to the emergency department (ED) after sustaining a fall. The patient was brought to the emergency room accompanied by his son and neighbor with complaints of severe pain in his left leg and hip area. Upon stabilization, the patient was scheduled for manual manipulation, relocation, and alignment of his hip. Although the procedure was done successfully, a series of events occurred leading to the deterioration of the patient’s condition and death seven days later.
During the investigation of this sentinel event, the issues contributing to poor management of the patient’s condition begin with poor staffing in the ER. As observed, there were only two nurses and one doctor in the department serving an increasing number of emergencies that day. For instance, Nurse J was taking care of two other patients including an eight-year-old boy with suspected appendicitis. It is clear that Nurse j was not in a position to handle a patient with hip dislocation while attending to the other patients. Perhaps, adequate staffing could have made it easy for the providers to keenly assess Mr. B and create a comprehensive plan that could address all the areas of his problem.
The second problem observed during care delivery to Mr. B is inadequate assessment and history taking. This challenge can be linked to a lack of enough time because of the busy nature of the ED during that day. For example, Nurse J and Doctor T failed to note the patient’s use of oxycodone for pain management and his weight as contributing factors to poor response to mild sedatives. During sedation, the patient was given 10 mg of diazepam and 4 mg of hydromorphone IVP and this led to poor recovery. Apart from issues with achieving conscious sedation, the patient was not monitored effectively during recovery. According to the hospital policies, patients under conscious sedation should remain on continuous B/P, ECG, and pulse oximeter throughout the procedure and until the patient meets specific discharge criteria (i.e., fully awake, VSS, no N/V, and able to void). Failure to adhere to these guidelines left the patient alone without a qualified provider to monitor his recovery.
Various factors contributed to poor management of the patient leading to the observed sentinel event. Firstly, Nurse J had enough time to assess the situation at the ED and call for additional backup because of the increasing number of patients. Failure to call for backup created an unnecessary shortage of providers that led to poor monitoring of Mr. B. For example, the patient was left alone against the hospital policies as the two nurses went to attend to other patients. The second contributing factor is ignorance or perhaps gaps in competence for the LPN. For example, the nurse entered the patient’s room and found that the oxygen saturation was 85%. Instead of putting the patient on oxygen and reporting the findings to Nurse J or Dr. T, the nurse reset the alarms and left the patient’s room. An intervention at this time like oxygen supplementation or calling respiratory therapy could have saved the patient’s life.
- Improvement Plan
The plan to decrease the likelihood of another sentinel event in the organization focuses on both institutional policies and individual practices for healthcare providers. The first point involves providing education and training to ED staff about moderate sedation and monitoring of patients. The healthcare providers should be informed about the use of various therapeutic agents to achieve moderate sedation, recommended dosages, and patient factors to consider. For example, taking the patient’s medication history can help to identify drug interactions that can lead to over-sedation or challenges with achieving sedation. During education, the providers should also be trained on monitoring of patients and red flags like desaturation that should prompt emergency response.
The second plan is to improve staffing in the ED and create a protocol for initiating backup in the ED. The sentinel event that occurred was mainly contributed by inadequate monitoring of the patient due to a shortage of staff. Two nurses were not enough to keep an eye on the patient while attending to many others in the ED. Apart from this plan, the healthcare organization should have a well-defined protocol for initiating backup in the ED. For example, the protocol should define the maximum number of patients staff can handle at a time and the conditions of patients in the ED that should prompt a call for backup.
Another improvement plan that should be incorporated to prevent the occurrence of a similar event is the definition of the roles of LPNs in the unit. According to the scope of practice for nurses, LPNs should work under the direct supervision of registered nurses and doctors. In the case study presented, the LPN nurse failed to report assessment findings to Nurse J when the patient’s condition was deteriorating. An oxygen saturation of 85% should have raised an alarm that the patient was experiencing respiratory distress following sedation. Ensuring that these providers are adequately supervised can enable RNs to make quick decisions that can save patients’ lives.
B1. Change Theory
Lewin’s change management theory is widely adopted in healthcare to guide the implementation of new changes. This theory explains that change can be implemented using three simple steps that include unfreezing, change, and refreezing (Burnes, 2020). The unfreezing stage serves to prepare the organization to accept that change is necessary. The change manager should determine what needs to be changed, understand why change needs to take place, support the change using evidence, and communicate the vision to the employees.
The second stage is implementing the actual change leading to new ways of doing things. The change manager should inform the employees potential benefits of the change, communicate effectively, and involve them in the change process. Lewin observed that this stage should be preceded by mentorship and monitoring to ensure employees do not go back to the old ways of doing things (Burnes, 2020). The refreezing stage is the ultimate step where people accept new ways of working, accept new ways, and establish new relationships. The change manager should identify what supports the change, ensure leadership support, establish feedback mechanisms, and create a reward system for employees.
Kurt Lewin’s change management theory can be applied to implement the identified improvement plan for the sentinel event. The first stage of unfreezing will involve presenting the facts about the event to the ED staff and establishing the need for changing their practices. The team will explain that implementation of the education and training for staff will improve their knowledge and skills for caring for patients with similar conditions. Remaining open to employee concerns and addressing them before implementing the changes will be important to promote acceptance of the change.
During the change stage, the team will organize an education and training session for ED staff on the areas of moderate sedation and monitoring of patients. Answering questions and providing adequate supervision will serve to strengthen the employees’ beliefs about the new change. Weekly assessment and communication of progress will serve to reinforce the change. The refreezing stage will be utilized by identifying any barriers and giving feedback to employees. Keeping the employees informed and celebrating success after some time will serve to strengthen the new changes.
- General Purpose of FMEA
Failure Modes and Effect Analysis (FMEA) is a systematic process that is adopted to identify how and where processes may fail, the impact of failure, and parts of the process that need change. The purpose of FMEA is to identify parts of a process that require change and how the change can be implemented to enhance process outcomes (IHI, 2017).
C1. Steps of FMEA Process
The Institute for Healthcare Improvement identifies five steps that can be used to conduct a failure modes and effect analysis. Step one involves the selection of a process to evaluate with FMEA. The team needs to identify a process that is simple because complex processes may lead to inaccurate results (IHI, 2017). In the case study identified, FMEA can investigate a process like moderate sedation for Mr. B.
The second step involves the recruitment of a multidisciplinary team to investigate the process. It is important to include everyone involved in the faulty process to ensure every point of patient care is accounted for (IHI, 2017). For example, the investigation of the sentinel event should include Dr. T, Nurse J, LPN, and the patient’s son. Step three involves having the team list all the steps in the process. For example, steps in moderate sedation of Mr. B will include history taking, assessment of current medications, administration of sedatives, hip reduction, and monitoring for recovery.
The fourth step of FMEA involves drawing a table containing the steps of the identified process and filling the columns. The team members should fill in information about failure mode, failure causes, failure effects, the likelihood of occurrence, risk profile number (RPN), and actions to reduce occurrence (IHI, 2017). The final step involves the use of RPNs to plan improvement efforts. Failure modes with the highest RPNs should be given priority because they are likely to affect the whole process.
C2. FMEA Table
See attached FMEA table.
- Intervention Testing
To test the interventions identified in the improvement plan I will use the PDSA cycle. The plan-do-study-act (PDSA) cycle is a systematic process that can be used to gain continual improvement of a change by planning it, observing results, and acting on what is learned (Coury et al., 2017). For example, one of the interventions identified is to educate and train ED staff on moderate sedation practices including monitoring patients after the procedure. Using the PDSA cycle, the planning phase will involve identifying goals and initiating the new intervention. The goal is to ensure all staff in the ED can manage patients on conscious sedation until full recovery. The second stage ‘do’ will involve observing doctors and nurses as they administer conscious sedation and monitor patients in the ED. The ‘study’ phase will involve assessment of progress, documenting patients that are successfully monitored, and success rates of the interventions. The ‘act’ phase will involve congratulating staff on areas that were perfectly done during the conscious sedation of patients and providing further education on aspects that may seem to be challenging.
- Demonstrate Leadership
Promoting quality. A professional nurse can demonstrate leadership in this area by participating in the formulation of institutional policies to improve patient care (den Breejen-de Hooge et al., 2021). For example, the professional nurse should identify areas like staffing that require change and involve the management team to recruit new employees.
Improving patient outcomes. A professional nurse can demonstrate leadership in improving patient outcomes by supporting initiatives within the institution that focuses on quality and patient safety. For example, the nurse can advocate for the participation of patients in meetings to air the challenges faced and propose possible solutions to their problems.
Influencing quality improvement activities. Quality improvement activities in healthcare include things like the reduction of medication errors and patient falls (den Breejen-de Hooge et al., 2021). A professional nurse can demonstrate leadership in this area by regularly reviewing reports and giving feedback to employees. For example, the nurse leader should review incident reports and communicate issues like patient falls in respective units.
E1. Involving Professional Nurse in RCA and FMEA Processes
Involving professional nurses in RCA and FMEA is important in promoting demonstrating leadership in areas of decision making and problem-solving. The RCA process involves the investigation of issues and coming up with solutions to improve processes within patient care. For example, the professional nurse is in a position to decide on staffing to ensure ED nurses can care for patients that require close monitoring. The professional nurse also demonstrates leadership by guiding the selection of RCA and FMEA teams, helping the teams to analyze the identified processes, and reviewing proposed solutions to see if they can benefit the patient and their overall impact on the organization. For example, some solutions proposed by RCA and FMEA teams can only be achieved long term. The presence of the nurse leader in these teams will ensure analysis of solutions and proposal of realistic short-term and long-term goals for proposed changes.
Burnes, B. (2020). The origins of Lewin’s three-step model of change. The Journal of Applied Behavioral Science, 56(1), 32-59. https://doi.org/10.1177%2F0021886319892685
Coury, J., Schneider, J. L., Rivelli, J. S., Petrik, A. F., Seibel, E., D’Agostini, B., Taplin, S. H., Green, B. B., & Coronado, G. D. (2017). Applying the Plan-Do-Study-Act (PDSA) approach to a large pragmatic study involving safety net clinics. BMC Health Services Research, 17(1), 411. https://doi.org/10.1186/s12913-017-2364-3
den Breejen-de Hooge, L. E., van Os-Medendorp, H., & Hafsteinsdóttir, T. B. (2021). Is leadership of nurses associated with nurse-reported quality of care? A cross-sectional survey. Journal of Research in Nursing, 26(1-2), 118-132.
Driesen, B. E., Baartmans, M., Merten, H., Otten, R., Walker, C., Nanayakkara, P. W., & Wagner, C. (2022). Root cause analysis using the prevention and recovery information system for monitoring and analysis method in healthcare facilities: A systematic literature review. Journal of Patient Safety, 18(4), 342-350.
Institute for Healthcare Improvement. (n.d.). Patient safety 104: Root cause and systems analysis.Retrieved from http://www.ihi.org/education/ihiopenschool/Courses/Documents/SummaryDocuments/PS%20104%20SummaryFINAL.pdf
Institute for Healthcare Improvement (2017). QI essentials toolkit: Failure modes and effects analysis (FMEA). Retrieved from
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