Root Cause Analysis: Case Study
In a nursing context, such as that in the case under review in this paper, sentinel events are adverse occurrences whose consequences include serious harm or deaths of patients in the care of a health service. These events occur independent of the condition of a patient and reflect deficiencies in the processes or systems of hospitals or hospital units. The case of the patient who experienced a hemolytic transfusion reaction at the dialysis unit of the 500-bed hospital is comprehensible in this context. Despite the hospital’s service for over a century and its strong reputation for medical care, the sentinel event reflects a deficiency in the systems and processes that prevail or apply currently in the dialysis unit. It indicates that currently prevailing processes and systems in the unit feature a risk for the safety of patients. In effect, it is necessary for the nurse manager at the unit to lead a critical analysis of the event and its causes from all possible perspectives in order to identify and address this risk effectively, and hence guarantee the safety of patients and safeguard the hospital’s reputation for medical care.
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In the root cause analysis, it is necessary to include different aspects that reflect the interdisciplinary process necessary in the delivery of patient care services. An analysis of the patient’s case at the dialysis unit, it shall be important to consider the interrelationships among events and systems because actions in one area trigger those in another, and so on. The focus of root cause analysis would be on tracking these actions back to discover the origin of the problem and how it grew into the risk for the patient at the unit by investigating the human, organizational, and physical causes. The following components shall be important to include in the analysis (JC, n.d.):
- Analysis of whether the RNs and patient technicians followed the intended process and system flow in care for the patient
- Analysis of the human factors relevant in the case – human performance issues (boredom, lack of motivation, lack of knowledge/failure to follow procedures, fatigue, rush to complete the tasks, personal issues in life, substance use, lack of critical thinking skills, inability to focus on the task during the performance, inattention, confirmation bias, etc.)
- Analysis of the possible role of technology/equipment performance issues in the case (availability/application of equipment, equipment settings, etc.)
- Analysis of possible environmental factors in the case (lighting, space issues, etc.)
- Analysis of qualifications of staff to complete the tasks effectively (orientation/training, competencies, etc.)
- Analysis of the possible role of actual staffing level at the time of the event (workload, unusual circumstances, experience and skill mix among staff at the time, etc.)
- Analysis of the possible role of contingencies in the case
- Analysis of the possible role of information factors in the case – availability, completeness, clarity, and accuracy of all information when needed
- Adequacy, appropriateness, and efficiency of communications among staff at the dialysis unit in the event
- Analysis of ways to prevent a recurrence of the event, such as possible incorporation of technology, effective training and orientation, improvement of team/organizational culture, communications, etc.
- Comprehensive review: The analysis of these factors in the case of the patient’s case at the dialysis unit represents a comprehensive review focused on identifying the causal and contributive factors. This focus in the analysis is evident in investigations of the processes and systems that apply in the delivery of care and factors that underlie the event. The analysis is important to identify corrective actions to address the risk for patients at the dialysis unit effectively, implement the action to achieve systemic improvement of services at the unit, and monitor the effectiveness of the action to improve it continually. This review is essential to achieve and maintain efficiency, productivity, and excellence of the systems and processes that apply in care for patients at the dialysis unit in the hospital.
In the context of the need to make the analysis genuinely effective and inter-disciplinary, it shall be important to include other disciplines in the analysis team. The two other chosen disciplines to include in the team are human resources management and psychology.
Human resources management is a suitable discipline to include in the team because the investigation of factors that caused, contributed to, and underlay the sentinel event at the dialysis unit shall involve assessments of the performances of human beings in the unit. Human beings in the unit – registered nurses, patient care technicians, and staff in other departments – are assets that provide the skills and effort necessary to perform and complete the tasks necessary in care for patients at the dialysis unit. HRM focuses on maximizing the performances of employees in tasks in an organization or team to enable the achievement of the organization/team’s objectives (Bratton & Gold, 2012). In this context, including HRM in the team to analyze the problem is essential to assess the potential roles of all factors relating to employees’ and team performances in the unit and the hospital. These include motivation, levels of employees’ knowledge, skills, and competence, job-skill fit, workload, critical thinking skills, etc.
Psychology is a suitable discipline to include in the team owing to its focus on the significance of personality, feelings, thoughts, and interactions between the mind and body in the behaviors, choices, decisions, and performances of human beings. Psychology describes the study/science of mind and behavior, consciousness/unconsciousness as phenomena, and the processes of human feeling and thought. The discipline of psychology is important to include in the team to analyze the problem that the sentinel event has revealed at the dialysis unit because of its focus on exploring the roles that mental and behavior processes have in individuals’ behaviors, decision-making, and thinking (Kalat, 2016). It shall enable the analysis process to focus on factors such as perception, attention, intelligence, motivation, brain functioning, subjective experiences, emotion, cognition, and personality. It shall enable the analysis to investigate the possible roles that the experiences, thoughts, cognitions, attentiveness, motivations, and interactions among registered nurses, patient care technicians, and teams and staff in the unit and other departments in the hospital had as contributors, causes, and underlying factors in the sentinel event.
In the process of conducting the analysis, it shall be necessary to ask the team members about various issues to enable a comprehensive understanding of the problem and its causative, underlying, and contributing factors. These questions include:
- What challenges/problems did/do you identify and experience in the dialysis unit?
- How are the relationships and communications among registered nurses, patient care technicians, and other teams and staff in the dialysis unit/hospital?
- Do you think the nurses and technicians at the dialysis unit had/have adequate skills, abilities, and competencies to work with available equipment and deal with all normal and emerging tasks and demands of individual patients in the dialysis unit?
- Are the work conditions and environment at the dialysis unit and the hospital satisfactory?
- Are there any factors in culture, training, conditions of work, intra-team or inter-team relationships, or other areas of work and performance that you think could have contributed to the sentinel event?
“Framework for Root Cause Analysis and Corrective Actions” (n.d.). The Joint Commission.
Bratton, J., & Gold, J. (2012). Human resource management: Theory and practice. London, UK: Macmillan International Higher Education.
Kalat, J. (2016). Introduction to psychology. Boston, MA: Cengage Learning