Topics: Causality, Root cause analysis, Quality Pages: 9 (1535 words) Published: June 19, 2014
RTT Task 2
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.

Before the process can start, a team must be assembled as quickly as possible. The Institute for Healthcare Improvement suggests a multidisciplinary group of 4 to 6 individuals, including representation from a quality improvement department whenever possible (Huber & Ogrinc, 2014). The teams can then organize into roles such as; team leader, recorder, advisor and team members.

The team can then start the process of the root cause analysis, which is to identify what happened. Conversation among the team, review of documentation such as incident reports will assist in giving a general outline and understanding of the event that occurred (Huber & Ogrinc, 2014). The team can next further clarify the details, potentially conducting further interviews or a cite visit can be of assistance for this. It is important for the team to get as much detail as possible regarding the event for the RCA to be effective. A flow chart showing the process of the event can then be made to assist with the next steps of the stage.

Next, the team should determine what should have happened. This may involve policy and procedure review, research of best practice models and conversations with department heads and specialists (IHI, 2004). A separate flow chart can be made with this data, then compared to the flow chart of the event in question, for better understanding of where the process’s weakness lie.

The next step of the RCA is to identify both direct causes and contributory causes of the process failure. Direct causes are the most apparent factors for the error, in the given scenario it’s the failure to recover and monitor the patient post procedure. Because the patient was not monitored, the side effects of the medication caused respiratory depression, which, without proper intervention caused respiratory failure and eventual death.

The contributory factors are indirect causes of errors such as staffing issues, poor communication and failure to follow proper procedures, these factors are what should be the focus for change and restructure.

Contributing factors in the scenario include high dosing of narcotics and benzodiazepines, with little time between doses for effect to be apparent. The patient’s history of chronic narcotic use and assumption made by the physician that a tolerance had been generated. Failure to place the patient on supplemental oxygen, even with an oxygen level of 92%, which falls into the low normal range, and EKG and oxygen monitoring was not initiated for central monitoring at the workstation. The LPN disregarded the low alarming oxygen level and either a communication error occurred when the information was not passed on to the RN, or the LPN is in need of further training. Additionally, high patient census and low staffing were also contributing factors leading to this sentinel event.

Once identified the causative factors can be further broken down into groups for further organization and clarification. These main categories may include patient characteristics, task factors, individual staff members, team factors, work environment, and organizational and management (IHI, 2014). Next, use of a cause and effect, or wishbone graph can be constructed...
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