Department of Health and Human Services Paper
Root cause analysis is usually used as a management tool to improve efficiency in an organization. Depending on the type of business various root cause analysis models are developed for their particular purposes. Department of Health and Human Services Paper
Define a root cause analysis and when it is used.
A root cause analysis is a problem solving technique designed to identify and attempt a corrective measure for medical errors and other irregularities, which may occur from time to time during medical practitioner/patient/client interaction. It goes beyond addressing symptoms of the issue such as persons, but rather looks at systems, the environment and structures predisposing to the incident. The focus is to correct and not judge, while accountability is important collaborative approaches are adapted instead of individual patterns. It is performed when incidents occur resulting in accidental death or serious injury to clients/patients (Rooney & Vanden Heuvel, 2004).
In the case study identify the incident and explain the problem that might trigger a root cause analysis
The case study incident relates to a patient being admitted with septic shock to the intensive care unit of a hospital. This condition required prescribing and administering vasopressors. Subsequently the patent suffers a myocardial infarction (MI), which could have been due to the medication error increasing the vasopressor. The problem here is that a patient without previous MI condition should not have developed it as a complication when being treated for septic shock. This patient could have died due to this medical error. Prior to the Intensive Care Unit episode this patient was seen at the emergency where the medication management errors began (Flanders & Saint, 2005).
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Definitely, this condition requires a root cause analysis since it would appear that while errors have been reported in the system, they are taken for granted. However, this incident ought to serve as a lesson for preventing further situations, which can escalate into serious law suits. Root cause analyses are usually warranted when an entire team is involved in the incident. In this case the evidences offered indicate that a health care team was attending to this patient in the emergency room as well as intensive care unit. They were all responsible for the error. Hence, a root cause analysis is mandatory (Rooney & Vanden Heuvel, 2004).
Do you agree that the problem should not be investigated? Explain why or why not?
In my opinion the problem should be investigated. The sequel of this incident suggests that despite the patient’s previous health conditions after transfer to the Intensive Care Unit from emergency he was in a fairly stabled condition according to the medical evaluation. Norepinephrine was weaned gradually, but the patient remained on vasopressin. It was discovered hours after that instead of receiving 0.04 units/min 0.4 units/min was administered. Clearly it is medication management error (Flanders & Saint, 2005). Department of Health and Human Services Paper
Isha Patel and R. Balkrishnan (2010) researched Medication Error Management around the Globe and discovered that medication error is a perspective issue. As such, it is imperative to ‘establish systems that consistently disclose potential errors, reduce risks, and alleviate the effects of errors’ (Patel & Balkrishnan, 2010, p 539). More importantly, the institute of medicine report on Crossing the Quality Chasm: A New Health System for the 21st Century risk analysis revealed that many medication errors are due to system failures (Institute of Medicine, 2001).
They advance that an essential solution to this problem could be addressed effectively through giving attention to systems through which medication is administered since it would appear that the ‘ 5 rights’ jargon is not working by conducting a root cause analysis. When considering the number of steps a single medication order has to pass through it facilitates errors. The simplicity of the right dose, right route, right patient, right drug and right time has been replaced by systems which seldom acknowledge these steps in an organized manner. They are captured after an error occurs (Institute of Medicine, 2001).
Discuss the goals and limitations of root cause analysis
Goals of root cause analysis are to identify what, why and how accidents/ errors happened in order for preventing recurrences. Secondly, it is exploring what underlies the identified incident/s; deciphering if management strategies can be employed and recommendations be generated. Thirdly, gathering and documenting data through interviews, surveys, perusal of documents and case studies to be used as future references (Rooney & Vanden Heuvel, 2004).
Outline the steps to conduct a root cause analysis.
There are four steps to conducting a root cause analysis.
Step one—data collection. Complete data regarding the incident and an understanding of the essential factors, associated with it must be identified. This cannot be achieved without spending quality time applying the most appropriate data collection procedure in retrieving information from relevant sources. As such, data collection is a very essential aspect of root cause analysis.
Step two—Causal factor charting. (See Illustration)
As in any investigation when pertinent data has been retrieved it must be categorized and interpreted. Causal factor charting offers a structure whereby this process can be facilitated. A design which organizes and analyzes is developed. Gaps and deficiencies pertaining to the knowledge obtain during data collection are identified. Precisely, it is a sequence factor chart is consisting of logical tests describing events leading up to the incident and predisposing factors (Rooney & Vanden Heuvel, 2004).
Construction of this chart ought to begin as soon as the investigation opens and data collection procedures begin. A skeleton of responses are first designed and the charts expands as more relevant data is found
Step Three – Root cause identification.
When the complication of charting is completed, causal factors must be identified. From these factors investigators must identify a route cause. For example, in this case study whereby a 65 year old patient developed MI from overdose of vasopressin; after thoroughly checking the system; interviewing staff on duty that day; researching records pertaining to the specific instruction that was given form the drug and gaps occurring from the time order and execution a root cause for that incident must be identified (Rooney & Vanden Heuvel, 2004). . Department of Health and Human Services Paper
Step Four – Recommendation generation
Similar incidents must also be reviewed occurring at different times in the same institution on the two units involved, emergency and intensive care. A comparative analysis of incident must be undertaken by a subject matter expert who will tender recommendations to management or relevant authorities (Rooney & Vanden Heuvel, 2004).
Root Cause Analysis Steps
onclusion
The foregoing document embraced discussion of a case study incident requiring root cause analysis intervention. An evaluation of the incident was undertaken with the view of gaining insights into whether a root cause analysis was really necessary. Finally, four setps of root analysis incident application was tendered.
References
Flanders, S., & Saint, S, (2005).Getting to the Root of the Matter. Agency for Health Care Research and Quality Retrieved on August 6th, 2013 from http://webmm.ahrq.gov/case.aspx?caseID=98
Institute of Medicine (2001). Crossing the Quality Chasm: A New Health System for then 21st Century. Washington DC: National Academy Press.
Patel, I., & Balkrishnan, R (2010). Medication Error Management around the Globe: An Overview. Indian J Pharm Sci. 72(5): 539–545.
Rooney, J., & Vanden Heuvel, L (2004). Root Cause Analysis for Beginners. Quality Basics. Retrieved August 6th, 2013 from https://servicelink.pinnacol.com/pinnacol_docs/lp/cdrom_web/safety/management/accident_investigation/Root_Cause.pdf
Department of Health and Human Services Paper