1.Define a root cause analysis and when it is used.
2.In the case study identify the incident and explain the problem that might trigger a root
cause analysis.
3.Do you agree that the problem should not be investigated? Explain why or why not?
4.Discusses the goals and limitations of root cause analysis;
5.Outline the steps to conduct a root cause analysis.
522 MODULE 2 CASE STUDY
Question 1: Root Cause Analysis and its application
Root cause analysis refers to the process of identifying the causal factors of variation in
nursing activity, which leads to adverse, undesired and unexpected outcomes or even lead to
sentinel event. The process focuses on primarily on processes or systems with the aim of
understanding the potential causes of the variation that lead to error and identify the most
effective changes that will mitigate such failures in the future. Root cause analysis is often
performed to probe bad failures that may arise in nursing practice. It is also used to probe a near
miss event or as a process of performance improvement so as to redesign initiatives and to gain
understanding of variations in nursing practice (Holdsworth et al., 2015).
Question 2: Incident that might trigger Root Cause Analysis
In this case study, a patient was placed at the intensive care unit to manage septic shock
which required vasopressors suffered myocardial infarction (MI) during his treatment regimen.
The cause of MI was associated with prescription error, where the patient was given higher
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dosage of vasopressin. Medication errors are common, especially in critically ill patient. The
magnitude of these medication errors led to adverse effects. To understand the causative factors
of this incident and approaches to mitigate such incidences from occurring again, there is a need
to conduct a root cause analysis. In this context, RCA would be used to assess the environment
in which the incidence occurred. This includes assess the staffing levels in the healthcare setting,
product storage, patient identification process, labeling and also prescription ordering process
(Lee, Mills, and Watts, 2012).
Question 3: Is it necessary to conduct RCA for this case study?
In my perspective, it is vital to investigate the incidence in order to prevent such
occurrences from occurring. The RCA should be conducted in order to investigate what
happened, why it did, and what strategies can be done so as to prevent the incidence from re-
occurring. The benefits of RCA, it does not solely focus on an individual who wrote the wrong
order, but broadens the investigation to focus on the “root causes” of the incidence. The
underlying theory of RC is to move the understanding of these failures from human mistakes to
human factors that trigger the mistakes in order to engineer an approach that identifies the
systems vulnerabilities, and addresses the gaps identified (Grissinger, 2011).
Question 4: RCA goals and limitations
RCA process provides a systematic approach of investigating performance problems in
healthcare settings instead of relying in unverified assumptions and perceptions about the
causative factors. Secondly, RCA ensures that the healthcare facility inspect the identified issue
from broad perspectives with the aim of establishing a range of causative agents that led to the
undesired performance. RCA process opposes the idea that causes of the adverse effects are well
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known and are agreed upon by people involved. In most incidences, the RCA tool has the
capacity to identify the systems components that are blocking the desired performance and parts
of systems that promotes desired performance. This result in improved performance due to
routine fixing of issues and expansion of ideas that needs to be done right (Lee, Mills, and Watts,
2012).
On the other hand, RCA is associated with some limitations. For instance, RCA often
identifies many causal factors than anticipated or budgeted for. Therefore, it is important to
investigate the relative effect of the identified factors, and address the priorities critical to
patient’s safety and quality of care. In addition, the RCA involves complex procedures that may
not be familiar with the healthcare settings. The RCA focus on causes but does not inform one on
which interventions or activities best address each of the causal factor (Holdsworth et al., 2015).
Question 5 Steps for conducting RCA
The first step is the investigation phase. This involves the identification of a system
failure, and assessing the work environment and staff involved in the error so as to establish the
sequential flow of events. In this case study, this stage involves careful review of the incident
reported from the ICU and to check for near misses to allow identify the best practice for change.
The amount of information available in this case study is that a fellow resident staff gave a
verbal direction to pharmacist to order for vasopressin, the pharmacist entered the order directly
into a computer physician order (CPOE) system that had several lists of possible drug dosages,
an error was made which went undetected for more than 16 hours, and it involved
multidisciplinary teams rounds including nurses, physicians and resident pharmacist. The error
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was noted during a practicum session with nurse students who found that the patient was on
higher dosage (Joint Commission.org., 2011).
The next stage is to develop a plan to identify the identified need. This involves holding
interviews with the staff individually or through focus groups and record or document reviews so
as to collect information regarding the causal factors that led to the system failure. In this case,
the RC team led by health care facility patient safety and improvement program is established so
as to ensure that the process focus on the whole systems. Other team members would include
ICU nurse, ICU physician, ED representative and a pharmacist. The RCA team is responsible of
generating differential diagnosis data to identify factors that could have contributed to the
medication error (Grissinger, 2011).
The third step is analysis of the causatives factors identified. This stage is comparable to
the analogy of onion peeling because RCA involves analysis of many causal factors that underlie
many layers. At first step of analysis, the causes of failure system seem to be easily identified. In
most of ICU, the safety networks emphasis on patient’s quality and safe care and are often
committed to culture of safety. In this case study, the main investigation domain generated
includes events timeline, ICU protocols for high risk patients, patient safety culture,
communication practices, medication ordering protocol and staff working relationships (U.S.
Department of Health and Human Services, Agency for Healthcare Quality and Research, 2005).
The fourth step is identifying system failures solution. Unfortunately, there are no
standardized safety solutions that will aid in guiding the changes that should be made. This
indicates that the RCA team must research further to identify the key steps that will address the
contributing factors, and propose a reasonable system based solutions, implement the evidence
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based changes and to re-evaluate the process to ensure that there are no more problems will
occur. In this case study, the system errors can be developed such that there is complete
medication reconciliation and review patient entry and exit into ICU. The ICU safety officer
should round with team, review medication and non-medication related patient safety. A system
should be used to allow the fellow healthcare staff members to discuss medication errors so as to
encourage the likelihood of constructive changes (Grissinger, 2011; Anonymous, 2012).
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References
Anonymous (2012). Root Cause Analysis. Agency for Healthcare Research and Quality.
Grissinger, M. (2011). Including Patients on Root Cause Analysis Teams: Pros and Cons.
Pharmacy and Therapeutics, 36(12), 778–779.
Holdsworth, M. T., Bond, R., Parikh, S., Yacop, B., & Wittstrom, K. M. (2015). Root Cause
Analysis Design and Its Application to Pharmacy Education. American Journal of
Pharmaceutical Education, 79(7), 99.
Joint Commission.org. (2011). Joint Commission for the Accreditation of Healthcare
Organizations’ ” Sentinel Events” –
Lee, A., Mills, P.D., and Watts, B.V. (2012). Using root cause analysis to reduce falls with
injury in the psychiatric unit. Gen Hosp Psychiatry 34 (3): 304-311
U.S. Department of Health and Human Services, Agency for Healthcare Quality and Research.
(2005). “Getting to the Root of the Matter.”