Western Governors University
Root Cause Analysis of a Sentinel Event
A root cause analysis (RCA) is a method by which we can examine a serious adverse event and identify the cause, or causes, that led up to the event. Although personnel are involved in these events, the primary purpose of the RCA is to identify the cause, not to assign blame (Agency for Healthcare Research and Quality, 2014). It is through identifying a cause, or causes, of an adverse event that we can improve on patient care processes and thereby patient safety. The RCA is designed as a specific protocol that starts with data collection looking at the sequence of events that led to the adverse event (Connelly, 2012). Additionally a review of the patient record along with interviews of the personnel involved provides valuable insight into how the patient care processes broke down. Hospitals are complex organizations that have many layers of safety erected to protect the patient from action taken by healthcare providers. These safety measures include policies, protocols, and guidelines. The reason for multiple layers, or measures, is that there can be weaknesses in the process that forms an opening for an error to occur (Elliott, Page, and Worrall-Carter, 2012). The fundamental goal of the RCA is to prevent future patients from being harmed through understanding how an adverse event could occur.
Root Cause Analysis
We are examining the events surrounding the treatment of Mr. B in the emergency department for a dislocated left shoulder. Prior to Mr. B’s arrival at the emergency department (E.D.) on Thursday afternoon he reports that while showering he “just blacked out” and when he awoke his left arm was quite painful and obviously disfigured. Mr. B was brought to the hospital by his son and taken by Nurse J to an examination room to obtain a health history and physical assessment. Important facts to know
References: Connelly, L. M. (2012). Root Cause Analysis. MEDSURG Nursing, 21(5), 316, 313. Elliott, M., Page, K., and Worrall-Carter, L. (2012). Reason’s accident causation model: Application to adverse events in acute care. Contemporary Nurse, 43(1), 22-28. Horkan, A. M. (2014). Exploring the Evidence Alarm Fatigue and Patient Safety. Nephrology Nursing Journal, 41(1), 83-85. Institute of Medicine at the National Academies. (October, 2010). Retrieved from www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Nursing%20Education202010% McBride, T., and Kalogrianitis, S. (2011). Dislocations of the shoulder joint. Trauma, 14(1), 47-56. http://dx.doi.org/10.1177/1460408611413837 Ogg, M. J. (2012). Patient monitoring during moderate sedation administration. AORN Journal, 95(4), 541-543. http://dx.doi.org/10.1016/j.aorn.2012.01.014 Pinto, R.F., Bhimani, M., Milne, W.K., and Nicholson, K. (2013). Procedural sedation and analgesia in rural and emergency departments. Canadian Journal of Rural Medicine, 18(4), 130-136. Shin, S-J., Yun, Y-H., Kim, D.J., and Yoo, J.D. (2012). Treatment of Traumatic Anterior Shoulder Dislocation in Patients Older Than 60 Years. The American Journal of Sports Medicine, 40(4), 822-827. http://dx.doi.org/10.1177/0363546511434522 U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality. (October, 2012). Retrieved from www.psnet.ahrq.gov/primer.aspx?primerID=10