Root cause analysis (RCA)
Introduction
Root cause analysis (RCA) is a technique utilized by healthcare workers in the medical field to establish the core cause of an undesired event during a normal process of caring for patients. It acts as a tool for conducting a thorough analysis of the outcome of the event, and the results are comprehended fully to mitigate future problems while increasing and improving the safety of a patient.
Several RCA steps have been defined by the IHI, which include pinpointing the problem. Medical practitioners should be competent enough to identify the problem at hand when carrying out the RCA. It is the first step they should take when faced with life-threatening situations. Also, collect all the available details and information about the problem. Medics should conduct a thorough data collection and examination carried out to ensure that no information that would aid the definition of reasons as to why problems are not addressed.
Furthermore, evaluating to identify the sources that led to the rise of the problem is fundamental. After the collection of all the information about the problem, medical caregivers should evaluate all the information to identify the source of the problem and why it occurred. Information processed is used to identify possible roots of the problem. Further, the root causes of the problem are generated without overlooking any possible scenario. After the information has been processed, all the possible root causes of the problem are defined and how did they arise. Also, generate all the possible steps and recommendations to be taken to minimize health concerns in the prospect. This step allows practitioners to generate the necessary steps and recommendations that will be used to mitigate the problem in the future.
Develop an action plan that will be used to implement the most effective solutions. This is the last step in the RCA that is used to develop a detailed action plan inform of a document that can be used as a reference in the future when such an occurrence occurs.
Root Cause Analysis can be carried out to establish the occurrences that lead to Mr. B’s tragedy. Necessary steps should be taken to identify the problem and what should have been done. Mr. B suffered from brain death indicated by receiving hospital (Latino, 2019). The original hospital where Mr. B received first treatment had policies. The recommendations were continuous monitoring using a blood pressure machine, EGG, and monitor of oxygen saturation using pulse oximeter during the process until the patient stabilizes. The problem emerged when Mr. B was released from these after the operation while being monitored on automatic blood pressure and an SPO2 machine. The lack of any supplemental oxygen to Mr. B seemed to be the root cause of his eventual brain death. The lack of oxygen in the brain after the operation of Mr. B was overlooked through his lack of expressing any discomfort or distress. To improve the patient’s outcome required myriad approaches. The medical practitioners ought to have carried out vital analysis checks for the patient after the sedated operation. This was essential to check any potential harm or problems that the patient might not be able to communicate.
Kurt Lewin’s concept of change is comprised of three approaches unfreeze, changing, and refreeze. Before change is implemented, it should undergo the first step of unfreezing (Hussain et al,. 2018). This step involves creating awareness of how the current practices are hampering the organization. The second phase is change. Lewin notes that change is inevitable, and an organization should undergo. For the successful implementation of the change process, the organization must continuously prepare employees as they learn about new organization practices. Lewin’s final change model is freezing, however, some refer to it as refereeing. Lewin highlights that this phase is relevant in that it prevents tracking back into their initial old ways of operation. To maintain this state, an organization ought to introduce a system of rewards and appreciation to cement this change.
Failure Mode and Effects Analysis (FMEA) is designed to incorporate relevant measures to remove and/or, reduce weaknesses by first addressing the foremost followed by others. It also, record current information and key actions concerning the risk of failure, in order to use it to advance change. The steps are outlined below (Jiang et al ,. 2017)
Step 1. Choosing an approach that is outstanding in evaluating performance. Then conduct FMEA on medication management despite its complexity. It is recommended that an individual opts for a single process to achieve success. The nurse can conduct FMEA scrutiny on the medication that needs to be ordered and the administration procedure.
Step 2. The process of recruiting a multidisciplinary group is an essential step as it ensures each of the teams’ decisions are used in the process. Often, some team members engage in the process to the end, while others are partial contributors to the process.
Step 3. Engaging health care teams is essential in completing the process. The steps should be identified and totaled. Steps outlined by the team as one should clearly illustrate the whole process.
Step 4. The team identifies the failures and lists both the reasons to aid in planning. Besides, the team should note “failure modes” that could/may arise; it, therefore, means, any step or action that may not succeed. In addition, potential causes should be highlighted alongside each failure mode.
Step 5. In the failure method, the health practitioner assigns the priority number a numerical value. It helps in gauging the probability of incidence, detection, and severity. RPN aids health practitioners to prioritize their care. It also aids in examining approaches to achieve success. For each failure mode noted, the team should answer and assign a score to questions such as the probability of occurrence.
Step 6. Analyzing the outcomes. Three totals are multiplied to achieve risk priority figures for any failures. For the whole process, the team should sum the individual risk priority extent that is likely to occur
Step 7. Use RPN to plan the care of the patients to improve their outcomes. Failure Modes that record elevated risk priority numbers are relevant sections of the process to focus most efforts for change on or simply they are the most priority areas. On the other hand, failure modes with least RPNs ought to be the least priority areas to focus on, for they do not cause a lot of effects compared with those that record the highest RPNs.
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 |
To test the interventions process, we calculate the number of risk priority number by multiplying the likelihood of an incident, of detection, and the pain threshold. Then the highest figure of RPN indicates priority areas while the least RPN figure shows the least area of focus. The professional nurse demonstrates competency in promoting quality care by reviewing clearly the medical history of the patient and informing the Doctor precisely. In improving patient outcomes, the nurse should take continuous monitor of the patients in order to record changes and act decisively. In influencing quality improvement activities, the nurse uses data to make effective clinical decisions to ensure the flow of information and close monitoring of patients. Professional communication is seen through the active listening of nurse J. through Mr. B’s narration demonstrates leadership qualities. She is able to assess that the patient is in severe 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.
