Root cause analysis paper:
Introduction:
Knowing how to maintain client safety has been identified by the Institute of Medicine as a competency that nurses must possess.
In developing your Root Cause Analysis consider the following areas of common error:
Medication errors
Diagnostic Testing
surgical errors
Health care acquired infection
errors in hand-off reporting and care
Other areas related to safety:
Infection Control
Hazardous Materials
Safe use of equipment
Falls
Seizure precautions
Seclusion and Restraints
Sentinel events refer to unexpected death or major injury, whether physical or psychological, or situations where there was a direct risk of either of these. Major investigation is required in the case of sentinel event. Sentinel events are classified as one of the following:
Major loss of function or death that was not expected with the client’s medical condition.
Client attempted suicide during round-the-clock care, a hemolytic transfusion reaction, wrong site or wrong client surgical procedures, rape, infant abduction, or discharge to the wrong family.
Failure to Rescue
most severe, and describes a situation where the client develops a complication that leads to death. In failure to rescue situations, there were client indicators that were missed by one or more health care personnel that indicated that a complication was occurring.
Guidelines:
The purpose of this assignment is to introduce the concept of Root Cause Analysis, as well as assist the student to increase understanding of Quality Control issues and how these activities relate to the professional nursing role. The student will develop an APA paper following the steps outlined below. Please use headers for each step.
Completion of your analysis helps in achievement of BSN Essentials: II. Basic organizational and systems leadership for quality care and patient safety, III. Scholarship for evidence-based practice, IV. Information management and application of patient care technology, V. Health care policy, finance, and regulatory environments, VI. Interprofessional communication and collaboration for improving patient health care outcomes.
Normally the student would gather data in the hospital setting with the benefit of a preceptor for guidance.
This semester this project will be conducted by analysis of one the most often reported Sentinel Events as well as reviewing an associated case study where litigation has occurred as a result of error in patient care.
Root Cause Analysis (RCA) are investigations of serious adverse events or close calls performed by a team with expertise in the area of investigation whose members were not directly involved with the error. The team’s goal is to determine what happened, why it happened, and what can be done to prevent it from happening again. Rather than focus on the individual, the RCA (Root Cause Analysis) broadens the focus to examine the “root causes” of the error and focus on prevention of similar future errors.
The Joint Commission requires facilities to complete a root cause analysis on all sentinel events. Link
Assignment:
Develop an APA Analysis Paper following the steps below. Please use headings and subtitles i.e. Step One etc
Step 1/Video Review
A. View the video below and record your thoughts associated with this medication error, describe the errors and discuss the possibility of a sentinel event involving medication developing in a hospital unit where you either work or have done clinical .
https://youtu.be/KkSDW44hxTk
Step 2 : Literature Review/Selection and analysis of Event
A. Select one of the most frequent reported sentinel events from this link, Sentinel Events (Links to an external site.) complete a brief review of the information from the link, select one of the events and provide a description. This will be the topic of a part of your paper. Find one additional professional article that pertains to your selected topic containing an associated RCA, complete a brief description of the article and the associated RCA. Example: Analysis of medication errors by RCA method and implementation of reducing strategies to improve patient safety in Hujjat Kuh-Kamari Hospital in Marand – 2017.
B. Application of the Joint Commission Root Cause Analysis and Action Plan Framework Template
The article you review should offer a good description of a sentinel event with an analysis, provide a complete description of the event. Next refer to the Joint Commission Root Cause Analysis and Action Plan Framework Template as a guide for your own analysis of the event. Provide a description of the action plan template then using the template to address the criteria below.
Describe the expected process (if it was a wrong medication given what is the normal process for preventing the administration of the wrong medication or if it is wrong surgical site, what is the expected or normal process for making sure you have the right site?)
Describe what went wrong or the error.
Using the template, discuss what types of factors were involved that resulted in the error (human, environmental, equipment etc.)
Be sure to include an evaluation of the staff, was there adequate staffing, level of education and preparation adequate, etc?
What barriers were present, what plan was implemented to prevent a further occurrence?
Step 3 : Interprofessional Communication
From review of your article, discuss how interprofessional teamwork is utilized in the analysis of a Sentinel event. What departments are involved in the analysis? i.e nursing, providers, pharmacy. Address the use of teamwork in making a plan to prevent another error, for example, different roles, better ways to plan care, sharing of responsibilities and different levels of expertise. What role does effective communication play in the process?
Step 4: Viewpoint Analysis
Analyze the impact of a sentinel event from the following viewpoints:
Nurse Manager (how does a sentinel event impact the nurse manager on the unit where the event occurred? What is their responsibility, what would be their role in future prevention?)
Patient and family (How are the patient and family impacted by a sentinel Event or near miss?) How might the family react, what might be emotions that you would expect?
staff nurse (what is the role of the staff nurse in an adverse event? what concerns might they have or what legal ramifications might be involved?)
physician (explore the physician’s role in a Sentinel Event)
organization (How does a sentinel event impact a hospital, consider legal, trust, financial concerns)
State Board (how does the State Board investigate a sentinel event?)
Public (what impact would a Sentinel event have on the community?)
Step 5: Relevance to Practice
Where do you see yourself in the process of experiencing a sentinel event, as a practicing nurse? Describe how quality of nursing care affects patient outcomes. what can you do as a practicing nurse to make better outcomes for your patients?
Findings should be submitted in a written paper in APA format.
Root Cause Analysis (2)
THE attachment includes the links and rubric to complete the assignment.
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