Root Cause Analysis is an integrated procedure that entails the determination of the underlying causes, which have led to the deviation from the normal, expected outcome in a medical procedure (Bowie, Skinner & de Wet, 2013). A deviation may ultimately result in a surprising and unwelcoming result, otherwise known as a sentinel event, similar to the one that occurred to Mr. B, in the case study above. Root Cause Analysis assists in identifying the mistakes in the system that led to the sentinel event and a future relapse prevented by rectifying these issues. For the process to be complete and effective, the events follow a chronological order. The defining characteristic in an RCA is to find a flaw in the system instead of piling blame on a single individual (Bowie, Skinner, & de Wet, 2013). This is because, in a health system, a sentinel event is mostly because of a mixture of several grave faults from almost all of the people involved.
The Institute for Healthcare Improvement (IHI) has set up a four-step layout on how a Root Cause Analysis ought to work. First, the RCA team should comprise of 3 to 5 people from various relevant health fields. This team should have at least one member representing all the phases of the administration process.
The four steps of an RCA include the following. The first step entails providing a description of what occurred. The RCA team comes up with a detailed, accurate, and chronological picture of what happened. A flowchart of the events is helpful at times. The second step involves defining what ought to have happened. The team needs to come up with a hypothetically perfect situation of what should have occurred and make a comparison to what took place in step one above. Third, we have to define the possible causes of the sentinel event. Through the use of Ishikawa or fishbone diagram, the team is to come up with loopholes in the system that lead to the sentinel event happening. These can be either hazards or error and mostly involve widespread factors such as faculty members, management, and even the patient involved. The fourth step is making casual statements. Finally, a connection between the cause and effect need to be developed by the RCA team. This involves a link between a hazard or error and the sentinel event, put down in a statement.
Root Cause Analysis of the Presented Case
A patient by the name Mr. B arrives at the rural hospital emergency department. The patient complains of pain on his left leg and around the hip region. The left leg is visibly shortened, and there is edema around the calf area with a limited range of motion and ecchymosis. The medical history shows that the patient has prostate cancer and glucose intolerance. Currently, Mr. B is under atorvastatin and oxycodone. Laboratory tests show elevated lipid and cholesterol levels. Upon evaluating the patient, the physician orders the nurse to administer diazepam, which they swiftly replaced with hydromorphone after having little effect. Sedation is finally achieved after another round of 2 mg of hydromorphone, and 5 mg of diazepam is administered to the patient. The physician then proceeds to relocate and align the hip joint appropriately.
Mr. B is in a stable condition afterward and put on a blood pressure monitor; his son is allowed in to be with him. His ECG and respirations are however not monitored. The nurse leaves to attend to other patients. The nurse then receives a distress call from the son concerning the blood pressure monitor alarm. The code team is in to stabilize the patient, a procedure that is successful after defibrillation and administration of vasopressors, reversal agents, and IV fluids. The family of the patient moves him to a tertiary hospital for advanced care where he succumbs to brain death after a week, the EEG revealed.
Steps 2 and 3
In an ideal and hypothetical situation, the following should have been done to ensure the prevention of errors and hazards. The rur
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