Applying the root cause analysis
Applying the root cause analysis
Explain the general purpose of conducting a root cause analysis (RCA).
Explain each of the six steps used to conduct an RCA, as defined by IHI.
Most often and RCA team involves four to six individuals from a mix of different professions. Each person should have fundamental knowledge of the problems and procedure involved in the accident. There is a total of six steps. The first step is to identify what happened. The team needs to explain what happened by organizing the information to clarify exactly what took place. The second step is to determine what should have happened. The team can create a chart to better understand what should have happened in an ideal situation. Number three is to determine causes (“Ask why five times”). This is how the team determines the factors that lead to the event. They look at the direct causes and the contributory factors as to why the incident happened. The fourth step is to develop causal statements. This is how they explain how the contributory factors lead to the bad outcomes. Step number five is to generate a list of recommended steps to prevent the recurrence of the event, which are changes that the team thinks will aid in preventing the error from happening again. The final sixth step is, write a summary and share it. This can help to engage people to aid in the steps of improvement (Institute for Healthcare Improvement).
Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome.
The first step is to identify what happened: Mr. B is a 67-year-old male who is 175lbs with a past medical history of, chronic back pain which he was taking oxycodone for, impaired glucose tolerance, prostate cancer, high cholesterol, and high triglycerides. He was brought to the Emergency department (ED) by his son and neighbor complaining of pain in the left leg and left hip. He states he lost balance and tripped over the dog causing him to fall. When he had arrived at the ED, his blood pressure, heart rate and temp were all within normal limits, and his respirations were noted to be elevated at 32 which could be from the severe pain he was experiencing, which he rated 10/10. He was noted to have shortening of the left leg, edema, ecchymosis, and limited range of motion. There were two nurses (an LPN and an RN), an ER doctor, one secretary, and hospital respiratory therapist on staff at this rural hospital. Mr. B was the third patient in the ER at the time of arrival. The doctor evaluated Mr. B and ordered the RN to give 5mg of diazepam IV push, when that did not have an effect after 5 minutes the doctor then ordered the RN to give Hydromorphone 2mg IV push which was given 10 minutes later. The doctor was still not happy with the results after 5 minutes so, he then ordered to give another 2mg of Hydromorphone and an additional 5mg of diazepam both IV push. The sedation goal of the doctor was finally achieved, and he performed a reduction of the left hip. The patient had tolerated the procedure and he was still sedated, without any supplemental oxygen placed. The ED was then notified of a patient on the way in for acute respiratory distress, so the nurse put the patient on an automatic blood pressure and pulse oximeter reading every 5 minutes and she left the room leaving the son to sit with the patient. Five minutes after the procedure had ended the patients blood pressure had decreased to 110/62 and his oxygen saturation decreased to 92%, remaining without supplemental oxygen, and without ECG and respiration monitoring. While the RN and LPN were occupied with the new arrival, Mr. B’s oxygen monitor was alarming to indicate his oxygen had dropped to 85%. Then Mr. B’s son came out to alarm the nurse that the monitor was ringing again, she finally entered the room to find his blood pressure at 58/30 and oxygen level at 79%, Mr. B had no signs of breathing and there was no palpable pulse. The nurse called a STAT code and resuscitative efforts were started, he was intubated, defibrillated, given reversal agents, given IV fluids, and given vasopressors. This lasted 30 minutes, the ECG returned to normal sinus rhythm, blood pressure was 110/70. Mr. B was fully dependent on the ventilator, his pupils were fixed and dilated, and he was not responding to stimuli. Mr. B was then transferred to a different hospital for care upon the families wishes. Seven days after this ER visit, Mr. B was given a “brain dead” diagnosis, the family decided to remove life support and Mr. B had passed away.
The second step is to identify what should have happened. The doctor and nurse needed to be trained on the conscious sedation protocols in place, as well as known the proper dose and proper drugs to be used in this situation. If the nurse knew the drug dosing, she should have questioned the medication that was ordered to give to this patient. The nurse should of abided by the hospital protocol and placed the patient on continuous blood pressure, ECG, and pulse oximeter reading throughout the procedure and until the patient meets the criteria for discharge which was, being fully awake, vital signs being stable, no nausea or vomiting, and able to void. When Mr. B’s oxygen saturation was dropping the LPN should have notified the RN, instead she just silenced the alarm from going off which defeats the purpose of the alarm. Finally, the ER should have called for additional nurses and staff to assist with the current patients to prevent any accidents from happening.
The third step is to determine the causes of the event. The direct cause of death would be the irreversible brain damage due to lack of oxygen for a prolonged period of time. The the contributory factors to the patient’s death would be the lack of staffing, the doctor over sedating the patient for the procedure, not adhering to the protocol for proper conscious sedation monitoring, and ignoring the patients alarm for low oxygen saturation.
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