Root Cause Analysis In Nursing

Root cause analysis is a collective term that describes a wide range of approaches, tools, and techniques used to uncover causes of problems (ASQ, n.d). Investigation starts with visible problem and or symptom followed by a series of what, how and why questions to identify the first level, higher level and finally the root cause of the problem or the system. The purpose of the inquiry is to identify the exact cause of the problem and then make a plan of action on how to eradicate or control the cause (Vidyasagar, A. 2015).
The following scenario illustrates how a root cause analysis is performed. While assessing a patient in a postoperative unit, a nurse notice that the patient is not breathing and activates and call for rapid response team backup. The crush cart is wheeled in and the monitor is connected but it won’t turn on. As emergency care continues, a second machine is brought from the next floor and patient improves. The team seats to discuss the outcome, points out the achieved points and areas of improvement, first on the list is that they cardiac monitor failed to turn on.
Why? Equipment was not charged and the charger cable could not be found, the investigator goes further and notice that the daily check log had not been signed for the last 6 days and staff on duty on those days say they forgot to check. The root cause could be process failure – equipment maintenance.
A proposed action item would be 1) Change monitor’s charger cable to a non-detachable one, 2) Allocate task to the shift leader and have the emergency equipment checked as per checklist for availability and whether they are functioning, 3) Supervisory check on whether the practice is being done weekly, random check during rounds and monthly and 4) Utilize technology by setting up a reminder message to charge nurse pager every day at 0900 am and to supervisor pager and email weekly and