Preview

Root Cause Analysis In Nursing

Satisfactory Essays
Open Document
Open Document
370 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
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.
…show more content…
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

You May Also Find These Documents Helpful

  • Satisfactory Essays

    Unit 4222 232

    • 313 Words
    • 2 Pages

    All identified risks should be reported to the nurse or the manager on duty that day so they can be corrected and a new risk assessment can be in…

    • 313 Words
    • 2 Pages
    Satisfactory Essays
  • Better Essays

    RTT TASK 2

    • 7486 Words
    • 19 Pages

    A. Complete a root cause analysis that takes into consideration causative factors that led to the sentinel event. (This patient’s outcome)…

    • 7486 Words
    • 19 Pages
    Better Essays
  • Better Essays

    Hourly Rounding

    • 1231 Words
    • 5 Pages

    A change that a nurse manager could implement that would help improve patient care is hourly rounding. In order to implement this change successfully, the nurse manager needs to clearly communicate the expectations, and then follow up with good monitoring. When the nurse manager sees the staff meeting the expectations the staff should be acknowledged rewarded/recognized and celebrated. On the other side, if the staff is not meeting the expectations they should be reminded, coached, and counseled. Sticking to the communicated expectations can have powerful results when the nurse manager diligently and consistently puts the plan into practice.…

    • 1231 Words
    • 5 Pages
    Better Essays
  • Better Essays

    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 failures and possibly ensure that this event would not happen in the future. Additionally, it is imperative to the process that four questions are answered: What happened? Why did it happen? What are we going to do to prevent it from happening again? How will we know that the changes we make will actually improve the safety of the system? (Ogrinc & Huber, 2013).…

    • 3223 Words
    • 93 Pages
    Better Essays
  • Powerful Essays

    Nurse Rounding

    • 3219 Words
    • 10 Pages

    ensure bed wheels are locked, ensure that patient area is clean and neat with all…

    • 3219 Words
    • 10 Pages
    Powerful Essays
  • Better Essays

    monitor alarm fatigue

    • 1244 Words
    • 4 Pages

    In Christensen, Dodds, Sauer and Watts (2014) article gathered information on nurses’ perceptions while working in a regional critical care unit (ICU, CCU, HDU) in Australia. Cvach’s (2012) article reviewed seminal research to find effective ways to decrease monitor alarm fatigue. The articles were found in the PubMed database using the keywords "alarm fatigue" and "clinical alarms". The articles were chosen to provide effective information on ways to minimize monitor alarm fatigue. The two articles discussed can help clinicians understand alarm fatigue and the adverse effects it has on nurses and patient safety. With education and proactive measures provided by the research articles, healthcare staff can assist in decreasing the excessive alarms and the undesirable outcomes that often accompany them.…

    • 1244 Words
    • 4 Pages
    Better Essays
  • Powerful Essays

    The hospital has been found to have increase clutter in the hallways, which is a fire hazard and is a safety issue. Nurses were found to be unfamiliar with proper verbal order procedures, how to use the range of orders received and what abbreviations that are prohibited within documentation. The trend shows areas that the hospital needs to implement audits, and education. An action plan will be devised that meets the needs of each unit and areas of non-compliance with proper follow up. In order to be the hospital of choice, administration needs to implement an action plan to address the fallouts. By reviewing non-compliant areas the hospital can assess how to prevent fallouts. Understanding the importance and benefits of The Joint Commission requirements provides the hospital with standards. These standards continue to help the hospital provide the best care.…

    • 1727 Words
    • 7 Pages
    Powerful Essays
  • Powerful Essays

    RTT1

    • 1535 Words
    • 5 Pages

    The provided scenario gives an account of a busy emergency department with competent staff, and the multiple errors that led up to the most severe error possible in healthcare, unnecessary death of a patient. A root cause analysis (RCA) can be utilized to help understand the systems at fault within the facility so that improvements can be determined and implemented to prevent any future occurrences (Cherry, 456). RCAs focus on systems rather than blaming individuals involved, therefore they are only appropriate in cases where there has been no willful negligence or criminal acts (Huber & Ogrinc, 2014). The overall purpose of RCAs is to find out the causes of the adverse event and determine how to keep similar errors from repeating in the future.…

    • 1535 Words
    • 5 Pages
    Powerful Essays
  • Good Essays

    Alarms In Nursing

    • 864 Words
    • 4 Pages

    Automatic alerts and/or alarms are a system that converts information on the progress of a monitored process or the condition of a monitored system into a signal suitable for human perception. Generally light or sound signals are used, for example, the flashing of a lamp, the ringing of a bell, or the sounding of a siren. Use of alarms has made a significant impact on nursing as we know it, by alerting clinicians that something wrong with patients or alarming nurses that something is in need of our attention. Alarms are found on most medical devices used at the bedside. These alarms sound every hour of every day. An analysis of alarms at The John Hopkins Hospital, Baltimore, Maryland, revealed a total of more than 59,000 alarm conditions over…

    • 864 Words
    • 4 Pages
    Good Essays
  • Better Essays

    Nurse Staffing Ratios

    • 1458 Words
    • 6 Pages

    Over the past number of years there has been a nursing shortage which has led to the need of more registered nurses in the hospital setting. This is due to the uprising acuity of patient care and a decrease in there overall hospital stay. In order for the patients to get safe and quality care, the staffing, education and experience of the nursing staff needs to be made a priority. Not only has the safety and quality of patient care suffered, the working conditions in hospitals have also got worse due to the hospitals not keeping up with increase demand of nurses (Welton, 2007). Hospitals that don’t have adequate staffing tend to have an increased rate of negative patient outcomes. Some of these negative outcomes that are potentially caused by the decrease in nursing care are shock, pneumonia, cardiac arrest and urinary tract infections (Stanton, 2004). This has led to state legislatures adding mandatory laws that promote adequate staffing regardless of the severity or acuity of the patients. The additional costs that are required to staff the hospitals with additional registered nurses are unfunded which means that staffing can be decreased in other work areas (Welton, 2007). This shortage is a problem that is affecting not only the patients, but also the staff. Nurse management and leadership play a significant role in finding a balance among all involved. Throughout this paper, the author will be discussing how the managers and leaders play a significant role in the issue of nurse staffing ratios in order to promote quality and safe care for the patients. Also, the author will discuss some tools and skills that are beneficial in supporting the nursing staff and the overall demands in the hospital…

    • 1458 Words
    • 6 Pages
    Better Essays
  • Satisfactory Essays

    Human error in nursing is usually unavoidable, unpredictable and unintentional. Further, some risks include language barriers, neglecting to follow the policy, in a hurry to complete the task. As a supervisor, I encountered a nurse who gave a patient the wrong medications. The error occurred when the patient answered to the wrong name, and the nurse failed to check the patient’s identification bracelet. Other errors can include carelessness on the behalf of the staff as well as not taking the time to listen to the patient (Raso & Gulinello, 2010). Therefore, the aims of the risk management are to reduce as well as prevent any risk to patients and the health facility. Risk factors may result in financial loss, preventable…

    • 276 Words
    • 2 Pages
    Satisfactory Essays
  • Good Essays

    Organize! Get experienced nurses to help you compile a list of what you do daily, and in what order. When you first come on duty, what do you need to do? Make a list: 1. Take report. 2. Assess patients. 3. Check for new orders. 4. etc. etc. You should include all daily activities, and set a level of precedence for them. Making a med list, with times for each patient to get their meds, is an example of particular items to have in hand. You will want a sheet which lets you check off what was given to whom, and when. Such worksheets should be as concise and simple to use as possible. Many units, or individual nurses in the unit, already have very good…

    • 751 Words
    • 4 Pages
    Good Essays
  • Satisfactory Essays

    The main problem is that nurse staffing ration is affecting patient's safety. Since there is no Nurse Technicians and not enough nurses, there is so much to do and not enough resources to help me. One of my patients is complaining of severe abdominal pain and the physician is angry with me because I wasn't able to bring the equipment to her. One of the actions I would do speak to the physician and explain to her that charge nurse is currently taking care of a serious patient. In addition, I will let her know that a patient who just had surgery is experiencing severe pain and I need to check on him first. The physician needs to understand that there are not enough nurses on this shift. I will also tell her that I will help her after I check…

    • 342 Words
    • 2 Pages
    Satisfactory Essays
  • Powerful Essays

    Root Cause Interventions

    • 1555 Words
    • 7 Pages

    In “Nobody Left to Hate: Teaching Compassion After Columbine”, Elliot Aronson (2000) was able to easily allow readers to understand the isolation experienced by students who commit violent attacks at school campus. The author also provided understanding around how quick-fix solutions can cause deeper isolation within students who are already marginal to the school’s social structure and root-cause interventions can assist with building empathy amongst students on a school campus.…

    • 1555 Words
    • 7 Pages
    Powerful Essays
  • Satisfactory Essays

    UNIT HSC2015

    • 425 Words
    • 2 Pages

    ‘In my workplace I would report this immediately to the manager OR NURSE IN CHARGE and also record all my concerns in detail in the DIARY if it is something that regards the equipment. if it is something that regards the resident I will record everything in the care plan.If these pose a risk to others I must also complete a health and safety sheet and a risk assessment. The equipment in question would need to removed and replaced IMMIDIATELY; the facilities would have to be deep cleaned and any equipment sterilised or replaced.’…

    • 425 Words
    • 2 Pages
    Satisfactory Essays