Root Cause Analysis
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In a healthcare facility where restoring life should be the main focus, a life suffered more and was prematurely lost. Patient Mr. B, 67-year old, who complained of severe pain at his left leg and hip area due to balance lost secondary to fall after tripping over his dog, was brought to the rural hospital for palliative care and management. Appropriate and intensive assessment, first aid, and referral to the Emergency Department physician were done accordingly. The ED physician, after reviewing the results, ordered diazepam 5mg intravenous push (IVP) for skeletal muscle relaxation which will aid in the manual manipulation, relocation, and alignment of Mr. B’s hip, and hydromorphone 2 mg IVP for pain control and sedation. Not satisfied with the achieved sedation level on Mr. B, the ED physician ordered same medications with same dosages, which were carried out by Nurse J. Successful reduction of Mr. B’s left hip took place without indications of discomfort or distress even without supplemental oxygen.
When other patients flocked to the ED, the nurse placed Mr. B on an automatic blood pressure machine programmed to monitor his B/P every five minutes and a pulse oximeter to attend to the other patients. After several minutes, the B/P and oxygen saturation of Mr. B deteriorated and no breathing and pulse can be detected, putting him to ventricular fibrillation. Cardiopulmonary resuscitation, intubation, defibrillation and other life support procedures and treatments were done to revive him. With the family’s request, Mr. B was transferred to a tertiary facility for advanced care. But after seven days, he was diagnosed of brain death that his family asked removal of life-support, and he subsequently died.
The cause of death may be accounted to the patient’s wish of life-support removal, but a critical thinking and observation tells that there has been something wrong to the care rendered to Mr. B.
To prevent such incidence to reoccur in the future, this research paper aims to use analyses and perform actions on the matter.
This action research uses root cause analysis (RCA) to focus on the errors and hazards in the care and identify where the breakdowns occurred and failure mode and effects analysis (FMEA) to identify specific solutions to prevent reoccurrence. Both aim to improve patient safety through an analysis of system weaknesses conducted by a multidisciplinary team.
Overall, this research utilizes Kurt Lewin’s change theory which involves fact gathering and strategic planning ensuring comprehension of all participants in what is expected of them correctly, and focusing in the area of communication, which is a necessity in nursing (Keith, 2006). Thus, the members of the interdisciplinary team included in the RCA and FMEA are the rural hospital physicians, registered nurses, and licensed practical nurses as they are the front-liners in giving healthcare. Everybody in the team is a member in the action research so that new ideas will be collated and evaluated amongst them.
Rouda (1995) cited by Keith (2006), suggests that involving everybody can make them “learn and become accustomed to the new processes involving their work.” Keith (2006) elaborates this stating that interaction in the planning process for change is important because it provides a “hands-on feel of how the new methods are going to affect individuals own behaviors” and this further helps counteract resistance to change from the affected members of the healthcare team.
A Root Cause Analysis on the Premature Death of Mr. B
Communication is an integral skill a nurse should have. This analysis focuses on the lack of communication within the care process. There were at least three incidences of breach in the communication process: between the nurse and ED physician on verification on the medication, between the nurse and other healthcare team members on endorsement or designation of care, and between the nurse and other concerned people on the referral of abnormal findings.
Firstly, when the ED physician ordered administration of hydromorphone after administration of diazepam and another order for second round of diazepam and hydromorphone five minutes after the first round, the nurse did not verify or question the order. Instead, the nurse carried the order out immediately and gave the medications. To review, diazepam is a benzodiazepine, anxiolytic, antiepeliptic, and centrally acting skeletal muscle relaxant. It was ordered for Mr. B as an adjunct for relief of skeletal muscle spasm due to inflammation of his leg and hip muscles and joints secondary to trauma.
The onset of diazepam (intravenous) is one to five minutes; thus, when evaluating that the first dose of diazepam had no effect to the patient after five minutes, the physician ordered another dose is alright. Besides, the usual dose of parenteral diazepam for muscle spasm is 5 to 10 mg (Karch, 2006). As a prudent professional, the nurse should have carefully monitored not only the B/P but also the pulse rate and respiration of the patient as diazepam causes respiratory depression (Mantooth, 2010). Further, the dose of opioid analgesics such as hydromorphone should be reduced by at least one-third or eliminated with intravenous (IV) diazepam (Karch, 2006).
Meanwhile, hydromorphone hydrochloride is an opioid agonist analgesic which is indicated for relief of moderate to severe pain. This medication, with required dose of 1 to 4 mg, is usually given intramuscularly or subcutaneously; given intravenously by slow injection over two to three minutes if no other route is tolerated (Karch, 2006). Four of its major hazards include hypotension, respiratory depression, respiratory and cardiac arrest. In this case, patients who are taking such medications should be given full attention and intensive care.
In the case of Mr. B, the nurse should have questioned the orders. Also, there was sufficient equipment available and in working order in the ED that day. Since respiratory therapy is in-house and readily available as needed, it should have been utilized as part of the treatment regimen. In the first place during the assessment, respiratory care should have been provided to Mr. B as he was suffering from fast breathing, with a respiratory rate of 32 breaths per minute.
Secondly, when new patients began flocking to the ED, the nurse left the patient without a healthcare professional at the bedside, but only his son who knows nothing about the healthcare processes and machines. Even if the regular staffing during the day of the incidence consists of two nurses (one registered nurse and one licensed practical nurse), one secretary, and one ED physician, there has been always an available backup staff. The nurse has the power to delineate tasks to these additional staff when new patients were brought to the ED. And before, the nurse went out of the room, safety should be her first priority. Knowing the adverse effects of the given drugs, she should have administered supplemental oxygen.
Lastly, when Mr. B’s oxygen saturation alarmed showing a low result with 85%, the LPN attended to it but just briefly, only resetting the alarm and repeating the B/P reading. She should have conducted further assessment and referred the result to the RN or to the ED physician, knowing that the normal range of oxygen saturation is 95% to 100% (Harvard University, 2010) and that 85% is already a warning sign. And since, the problem is on oxygen, she should have anticipated administering supplemental oxygen.
A Failure Mode and Effects Analysis (FMEA) on the Case
The failure mode and effects analysis (FMEA) projects the likelihood that the suggested process improvement plan will not fail. Before achieving FMEA, there are pre-steps to be considered. In this endeavor, there should be an advisor and team leader. Together, they discuss about the process, determine what information are needed to be collected and what information is needed to be distributed to the team members. The needed data may include clinical practice guidelines, policies, applicable instructions, reference materials, and current literature that are pertinent to the process. Data that are available such as patient safety events reports, discharge data, and other relevant information collected internally or sent externally related to the process being examined.
To further make the analysis clearer, flowcharts may be drawn and presented for narrowing the scope of the process.
Then, during the meeting of the team, brainstorming is done for the potential failure modes and potential effects of failures are listed.
The most critical steps on FMEA are rankings on severity, occurrence, and detection, which follow next. These rankings help in prioritizing significant plans and actions to address the matter.
Severity ranking. This ranking is an “estimate of how serious an effect would be should it occur” (Resource Engineering, Inc., 2009). In determining the rank of severity, the impact of the effect would have on the hospital patients, on the overall hospital procedures or processes, and on the nurses and other healthcare members are considered. The ranking is rated using a scale range of 1 to 10, with 10 as “dangerously high severity leading to a hazard without warning” and 1 as extremely low severity (Resource Engineering, Inc., 2009).
In this research, the concern having the most severe ranking is on the problem on the communication process between the nurse and ED physician on verification on the medication. Communicating referral of abnormal findings comes in second while endorsement or designation of care poses low severity.
Occurrence ranking. On this ranking, the likelihood or frequency that the mechanism of failure or the cause will occur or reoccur is considered. To be able to accomplish this ranking, finding the root cause is important. Investigating and gathering data from complaints of the patient, pertinent reports and documents, and equipment maintenance records are the best methodologies in finding and solving the problem.
Similar to severity ranking, occurrence ranking makes use of a relative scale from 1 to 10, with an occurrence ranking of 10 meaning the “failure mode occurrence is very high, and happens all of the time” and 1 meaning the “probability of occurrence is remote” (Resource Engineering, Inc., 2009).
This research paper regards medication error due to ineffective communication as the top occurrence ranking mode. One of the effects of this mode is administration of overdosed medication. According to a study by the Food and Drug Administration cited by Stoppler (2009), “the most common error involving medications was related to administration of an improper dose of medicine, accounting for 41% of fatal medication errors.” Further, the study mentions that “almost half of the fatal medication errors occurred in people over the age of 60” (Stoppler, 2009).
Again, communicating referral of abnormal findings comes in second in frequency and endorsement or designation of care has remote probability of occurrence.
Detection ranking. Evaluating the current process controls in place, detection ranking is assigned after identifying the process-related controls which can take the place of the failure modes. Like the severity and occurrence scales, the detection ranking is also determined through a relative scale of 1 to 10. A rate of 10 means that “there is absolute certainty of non-detection”, signifying that there are no controls in place to prevent or detect the failure mode, and a rate of 1, on the other end, means that there is a certain chance of detecting a failure (Resource Engineering, Inc., 2009).
With these three critical steps – severity ranking, occurrence ranking, and detection ranking – the next step can now be achieved.
Developing an action plan to address the matter comes after identifying priorities.
An action plan is needed to guide the concerned health care team. The plan consists of the action or project or program to be done, the objectives specifying short-term and long-term goals, time frame, people concerned, strategies, and evaluation. In short, the plan of actions should observe the SMART guideline – specific, measurable, attainable, realistic and result-oriented, and time-bound.
To test the interventions in improving care by changing the process of care, a leeway of at least one month to one year experiment on taking action can be considered. If the suggested implemented action is successful in reducing or eliminating the problem, then it can be adopted and fully implemented.
In every endeavor, it is but important to conduct re-evaluations to determine the impacts of the changes or improvement.
Conclusion and Recommendations
Based from the root cause analysis, there really has been negligence on the part of the Emergency Department of the rural hospital that day. The medication error, lack of care, and non-referral incidences all trace the problem to ineffective communication. From this, the FMEA result ranks medication error due to ineffective communication as the top priority in severity, and occurrence, communicating referral of abnormal findings comes in second in frequency and severity, and endorsement or designation of care has remote probability of occurrence and severity. All three has average detection ranking as there is certain chance of detecting a failure in them.
From the findings above, it is therefore recommended that the healthcare team, especially the nurses, should review and act on their roles and functions well, aside from being a caregiver.
As patient advocate, nurses should fight for the rights of the patient on his behalf. From the case above, the nurse should have considered the patient’s bill of rights.
A nurse should also be a researcher. With the problems that have arisen, a nurse should do studies and share the findings to the healthcare team for prevention of reoccurrence of the problem. Thus, this action research is one way of fulfilling such role.
Further, it is also recommended that regular evaluation of the personnel, procedures, and policies in the healthcare setting should be conducted.
Harvard University. (2010). Oxygen saturation test. Retrieved May 19, 2010, from http://www.health.harvard.edu/diagnostic-tests/oxygen-saturation-test.htm
Karch, Amy M. (2006). 2006 Lippincott’s nursing drug guide. Philadelphia: Lippincotts Williams & Wilkins.
Keith, Mary. (2006, April 12). Change theory: the motivation it gives to health care nursing. Retrieved May 19, 2010 from http://www.en.articlesgratuits.com/change-theory-the-motivation-it-gives-to-health-care-nursing-id374.php
Mantooth, Robin. (updated 2010, January 28). Toxicity, Benzodiazepine. Retrieved May 19, 2010, from http://emedicine.medscape.com/article/813255-overview
Resource Engineering, Inc.. (2009). 10 steps to conduct a PFMEA. Retrieved May 19, 2010, from http://www.qualitytrainingportal.com/resources/fmea/fmea_10step_pfmea.htm
Stoppler, Melissa Conrad. (Reviewed 2009, September 28). The most common medication errors. Retrieved May 19, 2010, from http://www.medicinenet.com/script/main/art.asp?articlekey=55234