Introduction
The main reason for performing a root cause analysis (RCA) Root cause analysis (RCA) is a technique used by healthcare professionals to identify the fundamental reason behind an undesirable event that occurs as part of routine patient care.
It serves as a tool for doing a complete investigation of the event’s outcome, and the findings are thoroughly understood to prevent further issues while enhancing and improving patient safety.
When conducting the RCA, medical professionals ought to be qualified to recognize the current issue.
When faced with potentially fatal circumstances, it should be their first course of action.
Additionally, gather all the relevant facts and specifics concerning the issue.
To ensure that no information that would aid in the definition of reasons as to why problems are not handled is present, medical professionals should carry out a thorough data collection and examination.
Additionally, The main reason for performing a root cause analysis (RCA) is it is crucial to evaluate in order to pinpoint the root causes of the issue.
Medical professionals should assess all the information they have gathered regarding the issue after gathering it all in order to pinpoint the issue’s origin and cause.
To find potential problem roots, information is processed.
Additionally, the problem’s core causes are developed without excluding any conceivable situation.
After the data has been analyzed, all potential causes of the issue are identified along with their origins.
Also, come up with every suggestion and action that can be made to reduce any health issues.
This process enables professionals to develop the necessary actions and suggestions that will be used to alleviate the issue going forward.
Create an action plan that will be utilized to put the best options into practice.
The RCA process ends with this stage, which is used to create a thorough action plan that will serve as a reference should a similar incident recurs in the future.
Root cause analysis can be used to identify the incidents that contributed to Mr. B’s tragedy.
To determine the issue and what ought to have been done, necessary actions should be conducted.
Mr. B had brain death, as evidenced by his hospitalization (Latino, 2019).
There were rules in place at the original hospital where Mr. B received his initial care.
The advice was to keep the patient under constant observation using a blood pressure monitor, an EGG, and a pulse oximeter until they reached a stable condition.
After the operation, Mr. B was freed from these while being checked by an automatic blood pressure and a SPO2 machine. This is when the issue started to arise.
Mr. B’s final brain death appeared to be largely due to the absence of any further oxygen.
Mr. B’s failure to communicate any agony or distress led medical professionals to ignore the shortage of oxygen in his brain following surgery.
The patient’s outcome needed to be improved through a variety of strategies.
Following the sedation surgery, the doctors should have performed vital analysis tests on the patient.
This was necessary to rule out any injury or issues that the patient might be unable to express.
Unfreeze, altering, and refreeze are the three approaches that make up Kurt Lewin’s idea of change.
It should go through the unfreezing process as the initial step before change is introduced (Hussain et al,. 2018).
This stage entails raising awareness of the ways in which the organization’s current practices are problematic.
Change is the second stage.
Lewin says that since change is unavoidable, an organization should go through it.
The company must regularly train staff as they become familiar with new organizational procedures in order to successfully conduct the transformation process.
Although some people call it refereeing, Lewin’s final change model is called freezing.
Lewin emphasizes that this stage is important because it keeps employees from reverting to their early, outdated methods of operating.
Failure Mode and Effects Analysis (FMEA) was created to include pertinent steps to eliminate and/or reduce vulnerabilities by focusing on the most pressing issues first, then others.
In order to use it to advance change, it also keeps track of pertinent facts and important actions relating to the risk of failure.
The actions are described below (Jiang et al ,. 2017)
Step 1: Selecting a superior performance evaluation strategy.
Then, despite its complexity, perform an FMEA on drug management.
It is advised that someone choose just one process in order to succeed.
The nurse can examine the medication that needs to be ordered and the administration process using the FMEA method.
Step 2: Recruiting a multidisciplinary team is crucial since it guarantees that each team’s decisions are taken into consideration.
Frequently, some team members participate fully in the process while others only contribute in part.
Step 3: Getting medical teams involved is crucial to finishing the procedure.
The actions must be listed and tallied.
The team should have explicitly defined each step and broken the process down into those steps.
Step 4: To help with planning, the team recognizes failures and specifies both causes.
The team should also record any “failure modes” that could or might occur; this includes any steps or actions that might fail.
Along with each failure mode, potential causes should be indicated.
5. The health professional gives the priority number a numerical value using the failing approach.
It aids in calculating the likelihood of occurrence, discovery, and severity.
RPN helps doctors prioritize their patient care.
It also helps in analyzing strategies for success.
The team should respond to and grade questions like “chance of occurrence” for each failure mode listed.
Step 6. Analyzing the results is step six.
To calculate the risk priority numbers for any failures, three totals are multiplied.
The team should total the individual risk priority extent that is anticipated to occur for the entire process.
Step 7: Plan the care of the patients using RPN to enhance their results.
The essential process steps on which to concentrate the majority of your efforts for change are Failure Modes that record increased risk priority numbers, or simply put, they are the most important areas.
However, failure modes with low RPNs should receive the least attention because, in contrast to failure modes with high RPNs, they do not produce as many impacts.
The main reason for performing a root cause analysis (RCA)
Failure Mode Effects Analysis Table
| Steps in the Improvement Plan Process * |
Failure Mode |
Likelihood of Occurrence
(1–10) |
Likelihood of Detection
(1–10) |
Severity
(1–10) |
Risk Priority Number
(RPN) |
| 1.Doctor orders on the effectiveness of medication |
Wrong quality of drugs |
4 |
5 |
3 |
60 |
| 2. Doctor’s admission on the wrong patient |
Wrong patient |
5 |
5 |
5 |
125 |
| 3.Doctor unaware of previous existing allergies |
Poor review of the medical history of the patient |
4 |
2 |
5 |
40 |
| 4.Blood samples taken are put in RN pocket and labeled later. |
Incompetence in analyzing samples immediately. |
3 |
3 |
5 |
45 |
|
|
|
|
|
Total risk priority number
270 |
The likelihood of an incident, the likelihood of detection, and the pain threshold are multiplied to determine the risk priority number, which is used to test the effectiveness of interventions.
The main reason for performing a root cause analysis (RCA)
Then, the greatest RPN value represents priority locations, while the lowest RPN figure displays the least focused area.
By evaluating the patient’s medical history in detail and providing the doctor with exact information, the professional nurse exhibits her skill in promoting quality care.
The nurse should keep a close eye on the patients to record changes and take appropriate action in order to improve patient outcomes.
The nurse uses data to support clinical decisions that enable the flow of information and careful monitoring of patients in order to influence quality improvement efforts.
Through Mr. B’s narration, leadership qualities are demonstrated, and nurse J’s attentive listening exhibits professional communication.
She can tell that the patient is in excruciating pain.
References
Hussain, S. T., Lei, S., Akram, T., Haider, M. J., Hussain, S. H., & Ali, M. (2018). Kurt Lewin’s change model: A critical review of the role of leadership and employee involvement in organizational change. Journal of Innovation & Knowledge, 3(3), 123-127.
Jiang, W., Xie, C., Zhuang, M., & Tang, Y. (2017). Failure mode and effects analysis based on a novel fuzzy evidential method. Applied Soft Computing, 57, 672-683.
Latino, M. A., Latino, R. J., & Latino, K. C. (2019). Root cause analysis: improving performance for bottom-line results. CRC press.
Related Posts:
