The Root Cause Analysis
This writing will discuss the way to conduct the root cause analysis of the medical errors happened when a nurse gave the medications to the wrong patient. As the hospital’s risk management specialist, several questions would be answered. The writing would discuss what the hospital’s risk management specialist would do face to such a medical error. It will find out what question the risk management specialist would ask. It will also address the process to complete the root cause analysis. The process includes, but not limited to the staff interview, the policies reviewing, debrief, and the prevention.
We will first define the concept of the root cause analysis. Then, we will address the questions about the case study. “The goal of the RCA process is to find out what happened, why it happened, and how to prevent it from happening again. Because our culture of Safety is based on prevention, not punishment, RCA teams investigate how well patient care systems function. We focus on the ‘how’ and the ‘why’? Not on the ‘who’” (US Department of Veterans Affairs). This paper will be based on the above concept to address the concept of the medical error that happened in the case study.
Patient safety is an important part of the health care process. Patient safety allows to reduce harm and preventable medical errors. It also allows to lower the healthcare costs. According to World Health Organization; “Error is the failure of a planned action to be completed as intended (i.e. error of execution) or the use of a wrong plan to achieve an aim (i.e. error of planning) (3). Errors may be errors of commission and usually reflect deficiencies in the system of care.”
Medical errors can have negative consequences for the patients. These consequences include, but not limited to errors and delayed diagnosis and treatment. According to American Family Physician 2003; “In two studies about medical errors, family physicians reported health, time, and financial consequences in nearly 85 percent of their error reports. Health consequences occurred when the errors caused pain extended or created illness, or placed patients, their families, and others at greater risk of harm.”
Risk Management Specialist Responsibilities
A risk manager is responsible for analyzing and evaluating the business risk. He or she is also in charge of evaluating the medical errors and he or she determines the financial and general risk of errors in the business. In the medical setting, the risk manager analyzes the medical errors and its general consequences for the patients and the office. According to Sokanu; “Risk managers perform a number of different job operations, but all with the purpose of minimizing possible risks or losses for the businesses they serve. These losses include property, personnel, or cash flow. Risk managers are responsible for identifying and dealing with any issues that may arise related to insurance or safety, which, if overlooked, could result in litigation.”
As the hospital’s risk management specialist, what I would do after this medical error?
As a hospital’s risk management specialist. First, report the medical error. Reporting errors, is an important act to minimize future errors. Then, evaluate the risk of this medical error for the patient who has received the wrong medications for example. Analyze the nature of the medications he or she has received. Review in detail the profile of each medicine that was given. That analysis would include, but not limited to the name of the medicine, its proprieties, the possible side effects, the dosage, the indications and contraindications.
Also; after reviewing that profile, it will be used the just culture approach to try to find out the root cause of that medical errors by analyzing the all system. That would involve every employee in searching the root cause of errors. Avoid only focussing on the medical error itself that happened. But, be focused on what was the cause and how to prevent it from happening again. It has been stated in one of my posts that; in the healthcare setting; for example, when a nurse makes a mistake by administering a wrong medication, people should be focused on the ‘why’ a mistake was made. They should not focus on the mistake itself. The cause determines the effect. Usually, in healthcare and somewhere else, people are more focused on the effect. They are less focused on the cause.
In this specific case, order or request to order all the necessary tests for the patient who has received the wrong medications to rule out any safety issues. Patient safety is an important part of the health care process. The mistake could be attributed to the negligence at any level; it could be attributed to a system failure. Then, the concept of just culture, will fairly find out where the problem was and then, it will try to fix it. The concept of just culture is based on trust and safety.
What questions would you ask?
Ask why this medical error happened. That question is important when searching the root cause of medical error. The ‘why’ seems more useful than the ‘whom’. Find out the cause would be more helpful than remain focused on people who make errors. Here are some questions that would be asked: Ask how the error happened. How often that kind of errors happened? Why the nurse was alone while the unit was full that day?
What staff would you interview?
Interviewed the nurses and their managers. Interviewed every employee if needed. The involvement of everybody will allow to find out the cause of the error. It would also allow to prevent the future errors or mistakes from happening.
What policies might you review in detail?
There are some relevant hospital policies explained in the text. Those policies are clear about the number of nurses on the unit on a night shift if the patient beds are full. There are also clear explanations about the patient’s medications. Review in detail all those policies. Not review only one policy; but, all. All those policies are clear. They needed to be followed and respected. By reviewing all the policies, found out where exactly the system has failed. For example, try to understand why the nurse brought the medicines to two patients at once while the policies state clearly that a nurse should not bring the medicines to two patients at once.’
Who would you want in the room for a root cause analysis meeting?
As aforementioned, have a meeting with every employee who can be involved in searching the cause. Those include; but not limited to the nurse managers, nurses, the office manager, team leaders, and the nurse who made an error. According to Josh Rothenberg (LCE); “Without employee engagement, an RCA program will not get off of the ground. Equipment operators are the best suited to identify when the onset of failure occurs, and can help the RCA facilitator understand what happened and when it happened. Maintenance personnel must be on board to ensure that physical evidence – like that frozen bearing or damaged impeller – doesn’t get thrown away. Even cleaning the oil residue off of a failure inner race can destroy potential evidence. To instill ownership and understanding, employees must be involved in creating the RCA process.” The above statement confirms that employee’s engagement and participation are important in the RCA process. Then, every employee must be involved in the RCA process in that error.
What else might we need to know to complete a root cause analysis?
We need to know how the system usually works in this medical telemetry unit for example. We need to know the rate of the medical errors in this facility. Try to find out how many times the concerned nurse has made the errors. Be focused on the respect of the Relevant Hospital Policies. Ask the right question to the nurses about the event. For example, ask: How the error happened? How often that kind of errors happens? Why the nurse was alone that day in the unit? Those questions must be answered.
What might you do to prevent this problem in the future?
To prevent such a problem in the future, it would be better to request the respect of the standard precaution in the unit. Demand for the absolute respect of the Relevant Hospital Policies. Any nurse would not be alone if the unit is full. Request the absolute respect of the guidelines. That approach would prevent the same situation from happening. The approach will be based on a just culture approach to improve the system. Also, involve the patients and their families in their care. It has been already stated in one of my posts that: Even if errors are frequently due to the complexity of the healthcare system in the United States, we need to recognize that some people repeatedly make the same errors that are avoidable. We strongly believe that disciplinary actions should be taken again those people to contribute in preventing errors in health care settings. It is why; tell the healthcare professionals to be ‘more careful’ or ‘vigilant’.
A risk manager is responsible for analyzing and evaluating the business risk. He or she is also in charge of evaluating the medical errors and he or she determines the financial and general risk of errors in the business. In the medical settings, the risk manager analyzes the medical errors and its general consequences on the patients and on the office.
He or she must request for the absolute respect of the Relevant Hospital Policies. Any nurse would not be alone if the unit is full. Request the absolute respect of the guidelines.
FOOD FOR ALL
Let’s Feed for Hope
Mohamed Elmahady CAMARA
American Family Physician (2003): Consequences of Medical Errors Observed by Family
Physicians; retrieved from http://www.aafp.org/afp/2003/0301/p915.html
LCE: Life Cycle Engineering: The People Side of Root Cause Analysis: Employee engagement
and participation; retrieved from
U.S. Department of Veterans Affairs: VA National Center for Patient Safety: Root Cause
Analysis; retrieved from http://www.patientsafety.va.gov/professionals/onthejob/rca.asp
World Health Organization: World Alliance for Patient Safety: WHO draft guidelines for
adverse event reporting and learning systems: From information to action: Definition;
retrieved from http://www.who.int/patientsafety/events/05/Reporting_Guidelines.pdf