HLT 605: Root Cause Analysis Template

HLT 605: Root Cause Analysis Template

Participants in the Root Cause Analysis (Indicate name and position)

  • Luke Livermore (School Administrator)
  • Anne Rosewood (Hospital Unit In-charge)
  • Michael Joseph (social worker) (Andersen, Fagerhaug, & Beltz, 2010)

Issues related to patient confidentiality? Yes, the patient confidentiality was not upheld. Even though the patient’s name was not mentioned by the nurses, the manner in which his case was being discussed made it pretty obvious to the woman who it was.  An action plan is indicated, the nurses should be cautioned about sharing patients information. (Mazqai, 2015)

Issues related to staff training or staff competency? Yes, part of the nurses training clearly stipulates that they should treat patient information with confidentiality as it forms part of the patient’s rights. A clear action plan should be implemented to review the topic of patient confidentiality with the staff through CMEs.

Equipment/device? No.

Nurses’ station location? Yes. The location of the nursing station is a factor that could be implicated in this matter.  The station is too adjacent to the patients thereby making it hard for the nurses or the health care team to share any information about the patients without it being overheard by the patients. The clear action plan in this case is to move the nursing station to a more private location (Mazqai, 2015).

Lack of or misinterpretation of information? No.

Communication? No.

Appropriate rules/policies/ procedures?     No, the policies, rules or procedures could have been laid out but the nurses may have failed to follow it.

Personnel issues?  Yes. Personnel issues may have been to blame in this matter; the woman feels that her children are at risk of getting HIV AIDS. This issue can be, sorted by patient education on infection and prevention of HIV AIDS.

Supervisory issues? No.

Improvement Action Plan. No

Adapted from (Andersen, Fagerhaug, & Beltz, 2010)

Strategies for Improvement Measure(s) of Effectiveness Responsible Person(s)

Action item #1:          The nurses and other workers should be re-trained on patient confidentiality and privacy. The focus should put emphasis on the fact that not mentioning the name alone does not make the information private (Mazqai, 2015).

Action item #2:          The unit administrator should organize for the nursing station’s location to be shifted to a more private and discreet place where whenever patient information is shared cannot overheard

Action item #3:          The patient (woman) should be taught about HIV AIDS and how the disease can be transferred from one person to another to allay her fears and anxiety. The social worker should also organize for community sensitization on the matter of HIV AIDS with a special focus on transmission; this will reduce the stigmatization.

Action item #4 the teacher who is HIV positive should be counseled. The social worker can organize for the counseling sessions.

Action item #5:          The hospital should revise their policy framework to include more specific guidelines on the matter of patient privacy and sharing of patient information.





Andersen, B., Fagerhaug, T., & Beltz, M. (2010). Root cause analysis and improvement in the healthcare sector (1st ed.). Milwaukee, Wis.: ASQ Quality Press.

Mazqai, M. (2015). Patient confidentiality. Nursing Standard29(49), 61-61. http://dx.doi.org/10.7748/ns.29.49.61.s44




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