C489 Task 2 (completed)

C489 Task 2 (completed)

REQUIREMENTS

Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. An originality report is provided when you submit your task that can be used as a guide.

You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.

A. Explain the general purpose of conducting a root cause analysis (RCA).

Before explain the general purpose of conducting a root cause analysis, we need to know what a root cause analysis is.  A root cause analysis is a method of solving a problem that is used to identify the root causes of problems, events, issues, outcomes, or faults.  When looking at healthcare an RCA is usually done retrospectively to study an event where a patient or patients are harmed or an unexpected/undesired outcome has occurred. The general purpose for conducting a root cause analysis is to figure out why the event occurred, serves as an input process for remediation, and setting up corrective actions to prevent the event from occurring again.  It is also a way to improve patient safety and prevent future harm to patients.  There is one reason an RCA is not appropriate and that is in cases of negligence or willful harm.

        1.   Explain each of the six steps used to conduct an RCA, as defined by IHI.

i)        Identify what happened

The first step is a team must try to describe and explain what happened as accurately and completely as possible.  A team usually consists of people at all levels within the organization who know the issues and processes the are involved with the incident that the RCA is being completed on.  Usually the team consists of four to six members and some teams even include the patients that were involved or the family members of patients involved.  During this step the RCA team members may use flowcharts to organize and draw a clearer picture of what happened and the information they have received.

ii)      Determine what should have happened

The next step for the team is to figure out what could have happened if the conditions were ideal.  At this step another flowchart with the new information should be made and compared to the flowchart from step 1. iii) Determine the causes (ask “why” five times)

At this step, the team looks at the factors that contributed to the problem or event.  During this step the group will look at two types of causes and they are contributory factors, which are indirect causes, and direct causes, which are the most apparent.  One of the most effective tools in this step is a cause and effect diagram, which is also known as a fishbone diagram.  By using this type of diagram it shows the possible causes of a certain effect.  There are seven different factors that influence medical error and clinical practice.  Some of those factors include work environment, team members, an individual staff member, and patient characteristics.These seven factors will also be looked at during this step. iv) Develop causal statements

A causal statement is what links the cause that is identified in Step 3 to its effects and then back to the original event that started the root cause analysis to begin with.  A causal statement contains three part which are: the cause, the effect, and the event.  By developing causal statements, you explain how the contributory factors contributed to the event or bad outcome.

v)      Generate list of the recommended actions to curb the recurrence of the problem The recommended actions are actions or changes that the root cause analysis team feels will prevent the event or error from happening again. These recommendations usually fall into one of nine categories and are classified byThe National Center for Patient Safety as either strong, intermediate, or weak actions.  The categories include:

standardizing equipment, updating or improving software, changing the physical plant, training or educating staff, developing new policies, simplifying a specific process, using cognitive aids like labels or checklists, using forcing functions that physically stop employees from making common errors, and ensuring redundancy by using backup systems.

vi)    Write a summary and share it

This is the chance to interact and engage your staff and key players to help work on the next steps of improvement in the process.  To better organize and clarify the event or error, a flowchart can be created to draw a picture of what happened and in the order it occurred.

2.   Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome.

When looking back at the scenario, Mr. B passed away seven days after going into cardiac arrest, which was a result of receiving sedation to fix a dislocated left hip.  There are several causative and contributing factors that lead to him going into cardiac arrest and eventually dying.

Two of the causative factors are the amount of sedation that he received in a specific amount of time was too much and the lack of proper equipment that was used for this procedure to occur. 

When looking at the first factor you need to look at the patient’s history and the medications that he was given.  You also need to look at how long it takes for the medications to take effect on the patient.  Mr. B was given a total of 4mg of