Medical Errors: Root Cause Analysis Assignment
Root Cause Analysis
- 1-2 page narrative cover letter (This is where you introduce your topic and include referenced information from the 5 articles you chose to do annotated bibliographies on. Refereneced information from all 5 articles must be inlcuded.
- Completed Root Cause Analysis Action Plan Framework Template
- An APA Reference list.
- 1-2 Page Narrative Cover Letter:
Typed narrative cover sheet (1-2 pages in length) providing the context for the event and suggestions for changes in policy/procedure, which would assist in prevention of future occurrences of the same type. Remember the discussion post you did in Week 2 describing the error you would evaluate? Consider revising that post in light of everything you have learned this term and using it as your cover letter. Medical Errors: Root Cause Analysis Assignment
- Completed Root Cause Analysis Action Plan Framework Template:
Do this part first! Download the "Root Cause Analysis Action Plan Framework Template" (attached to the top of this page), and answer each of the questions. Make sure you follow the instructions on the form.
Answer all of the questions in the template.
If you identify a finding that is a Root Cause, you mark is as needing an Action Plan (yes or no). If it is marked Yes, you address the Plan in the Action Plan section of the Template.
Also regarding the Action Plan item, list the Responsible Party (RN, CNA, MD, LPN, etc) and the Method: Method: Is the Action Plan item related to: Policy, Education, Audit, Observation or Implementation. Medical Errors: Root Cause Analysis Assignment
- Reference List:
Compile all parts of the annotated bibliography you created into one single reference list.
Cut and paste all 3 parts of the assignment into 1 WORD document
NUR 392: Root Cause Analysis Paper Grading Rubric
Criterion Exceeds Expectations
Partially Meets Expectations
Does Not Meet Expectations
Development and Content
Introduces and presents paper effectively and clearly; purpose is readily apparent to the reader.
Introduces and presents paper adequately; purpose is not consistently clear throughout the paper.
Introduces and presents paper somewhat effectively; writing has a clear purpose but may sometimes digress from it.
Introduces and presents paper poorly; purpose is generally unclear.
Development and Content
Develops paper with exceptional care, including all topics assigned in a seamless manner; provides a balanced presentation of relevant information and shows a thoughtful, in-depth analysis of the topics; reader gains insights.
Develops paper as assigned, including a full discussion of each topic assigned; information displays a clear analysis of the significant topics; reader gains some insights.
Does not fully develop paper as assigned and may ignore one of the three major issues or treat it in a cursory manner; analysis is basic or general; reader gains few insights.
Paper is undeveloped; paper does not relate to the assignment and includes very little discussion of the issues discussed in the course; analysis is vague or not evident; reader is confused or may be misinformed.
Cohesion and Insight
Ideas are supported effectively; writer shows clear evidence of having understood and synthesized course concepts; the application of concepts to the event chosen is exceptional.
Ideas are generally supported; writer shows evidence of having read, understood, and correctly applied the course concepts to the event chosen. Medical Errors: Root Cause Analysis Assignment
Many ideas are unsupported and it may not be clear whether the writer has understood or synthesized the concepts; application to the event may be incomplete.
Writing is incoherent and shows little or no insight; there is no evidence that the writer has read the assigned texts or understood the concepts.
Organization Arranges ideas clearly and logically to support the purpose or argument; ideas flow smoothly and are effectively linked; reader can follow the line of reasoning.
Arranges ideas adequately to support the purpose or argument; links between ideas are generally clear; reader can follow the line of reasoning for the most part.
Arranges ideas adequately, in general, although ideas sometimes fail to make sense together; reader remains fairly clear about what writer intends.
Arranges ideas illogically; ideas frequently fail to make sense together; reader cannot identify a line of reasoning and becomes frustrated or loses interest.
Writing demonstrates a sophisticated clarity, conciseness, and correctness.
Writing is accomplished in terms of clarity and conciseness and contains only a few errors.
Writing lacks clarity or conciseness and contains numerous errors.
Writing is unfocused, rambling, or contains serious errors.
APA Format Uses APA format accurately and consistently.
Uses APA format with minor violations.
Reflects incomplete knowledge of APA format.
Does not use APA format.
Final Score Note: Criteria are evaluated on a 4-3-2-1-0 basis. Total rubric points are converted first to a letter grade and then to a numerical equivalent based on a 0–100 scale: 23–24 = A (93–100); 22 = A– (90–92); 21 = B+ (88–89); 17–20 = B (83– 87); 16 = B– (80–82); 15 = C+ (78–79); 11–14 = C (73–77); 10 = C– (70–72); 5–9 = D (60–69); 0–4 = F (below 60).
Falls In Elderly Patients
Falls are a leading cause of disability and even death in older adults and when a fall occurs, it impacts on their independence. It is important to identify the risks associated with falling in the elderly, to be able to reduce the incidents of falls. The elderly population has an accelerated growth coupled with an increased prevalence of chronic degenerative diseases which oftentimes leads to a fall (Alvarez-Barbosa, 2016). Old age has a strong association with the risk of falls because of the biological, psychological and aging process which leads to structural and functional changes that accumulate gradually with increasing age. These changes decrease the performance of gross and motor skills, thereby causing weakness and encouraging them to fall (Alves, 2016). Another factor that contributes to falls in the elderly is the number and types of medications being given to them such as anti-anxiety medications, antidepressants, diuretics, hypnotics, and antipsychotic medications. Although the benefits outweigh the risks, these medications sometimes get them confused, drowsy and weak (Leland, 2012). Medical Errors: Root Cause Analysis Assignment. Cognitive ability and mental health issues should be evaluated within the context of the individual patient's social situation by being alert to the occurrence of any change in mental function. Using an organized approach to the varied aspects of geriatric health, healthcare providers can improve the care that they provide for their older patients. Changes in mental status can have a profound impact on elderly patients and their families (Miller, 2000). Safety should be our topmost priority and we should create a safe environment for the patients. Some of the ways by which a safer environment can be created include decluttering their space, ensuring the hallways are free of any item, frequent monitoring of patient, prompt response to call light, raised toilet seats, grab bars, self-locking wheelchairs/ rolling seated walkers, footwear for preventing slipping and tripping, helmets, wheelchair-related safety, equipment (body pillows, pool noodles, etc.) (Zubkoff, 2016). Medical Errors: Root Cause Analysis Assignment
|#||Analysis Question||Prompts||Root Cause Analysis Findings||Root cause||Plan of Action|
|1||What was the intended process flow?||List the relevant process steps as defined by the policy, procedure, protocol, or guidelines in effect at the time of the event. You may need to include multiple processes.
Note : The process steps as they occurred in the event will be entered in the next question.
Examples of defined process steps may include, but are not limited to:
· Site verification protocol
· Instrument, sponge, sharps count procedures
· Patient identification protocol
· Assessment (pain, suicide risk, physical, and psychological) procedures
· Fall risk/fall prevention guidelines
|Patient assessment, frequent vital signs and neurological checks, Placing bed in low position and call light within patient’s reach. Prompt response to call light. Effects of medication. Muscle weakness and confusion.||yes||yes|
|2||Were there any steps in the process that did not occur as intended?||Explain in detail any deviation from the intended processes listed in Analysis Item #1 above.||yes||no||no|
|3||What human factors were relevant to the outcome?||Discuss staff-related human performance factors that contributed to the event.
Examples may include, but are not limited to:
· Failure to follow established policies/procedures
· Inability to focus on task
· Inattentional blindness/ confirmation bias
· Personal problems
· Lack of complex critical thinking skills
· Rushing to complete task
· Substance abuse
Rushing to complete tasks because the nurse-patient ratio is poor.
|4||How did the equipment performance affect the outcome?||Consider all medical equipment and devices used in the course of patient care, including AED devices, crash carts, suction, oxygen, instruments, monitors, infusion equipment, etc. In your discussion, provide information on the following, as applicable:
· Descriptions of biomedical checks
· Availability and condition of equipment
· Descriptions of equipment with multiple or removable pieces
· Location of equipment and its accessibility to staff and patients
· Staff knowledge of or education on equipment, including applicable competencies
· Correct calibration, setting, operation of alarms, displays, and controls
|Neurogical assessments performed at intervals: every five minutes , every fifteen minutes, then every one hour, every four hours and then once in 8 hours.
Crash carts usually examined every night to ensure it’s up to date, and it’s usually kept at the nurses’ station for easy access.
Vital signs equipment are usually kept in the hallways.
|5||What controllable environmental factors directly affected this outcome?||What environmental factors within the organization’s control affected the outcome?
Examples may include, but are not limited to:
· Overhead paging that cannot be heard
· Safety or security risks
· Risks involving activities of visitors
· Lighting or space issues
The response to this question may be addressed more globally in Question #17.This response should be specific to this event.
|Tight spaces in the room for maneuvering of assistive mobility devices.||yes||yes|
|6||What uncontrollable external factors influenced this outcome?||Identify any factors the organization cannot change that contributed to a breakdown in the internal process, for example natural disasters. Medical Errors: Root Cause Analysis Assignment||Structural design of the facility||no||yes|
|7||Were there any other factors that directly influenced this outcome?||List any other factors not yet discussed.|
|8||What are the other areas in the organization where this could happen?||List all other areas in which the potential exists for similar circumstances. For example:
· Inpatient surgery/outpatient surgery
· Inpatient psychiatric care/outpatient psychiatric care
Identification of other areas within the organization that have the potential to impact patient safety in a similar manner. This information will help drive the scope of your action plan.
|Sub-acute care unit|
|9||Was the staff properly qualified and currently competent for their responsibilities at the time of the event?||Include information on the following for all staff and providers involved in the event. Comment on the processes in place to ensure staff is competent and qualified. Examples may include but are not limited to:
· Competency assessment (What competencies do the staff have and how do you evaluate them?)
· Provider and/or staff scope of practice concerns
· Whether the provider was credentialed and privileged for the care and services he or she rendered
· The credentialing and privileging policy and procedures
· Provider and/or staff performance issues
|Every employee went through orientation at employment, trained to deliver safe patient care, ensure good hygiene and also underwent competency tests to ascertain skills level.
Providers are board certified and licensed.
|10||How did actual staffing compare with ideal levels?||Include ideal staffing ratios and actual staffing ratios along with unit census at the time of the event. Note any unusual circumstance that occurred at this time. What process is used to determine the care area’s staffing ratio, experience level and skill mix?||Staffing ratio has always been an issue. A nurse has an average of 22 patients and more, a lot of times.||yes||yes|
|11||What is the plan for dealing with staffing contingencies?||Include information on what the organization does during a staffing crisis, such as call-ins, bad weather or increased patient acuity.
Describe the organization’s use of alternative staffing. Examples may include, but are not limited to:
· Agency nurses
· Cross training
· Float pool
· Mandatory overtime
· PRN pool
|During staffing crisis, on site staff are mandated to work overtime. Alternative staffing is mainly by PRN pool.|
|12||Were such contingencies a factor in this event?||If alternative staff were used, describe their orientation to the area, verification of competency and environmental familiarity.||No, PRN staff also get the same orientation full or part time staff get.||no||no|
|13||Did staff performance during the event meet expectations?||Describe whether staff performed as expected within or outside of the processes. To what extent was leadership aware of any performance deviations at the time? What proactive surveillance processes are in place for leadership to identify deviations from expected processes? Include omissions in critical thinking and/or performance variance(s) from defined policy, procedure, protocol and guidelines in effect at the time.||Staff performed as expected.||no||no|
|14||To what degree was all the necessary information available when needed? Accurate? Complete? Unambiguous?||Discuss whether patient assessments were completed, shared and accessed by members of the treatment team, to include providers, according to the organizational processes.
Identify the information systems used during patient care. Medical Errors: Root Cause Analysis Assignment
Discuss to what extent the available patient information (e.g. radiology studies, lab results or medical record) was clear and sufficient to provide an adequate summary of the patient’s condition, treatment and response to treatment.
Describe staff utilization and adequacy of policy, procedure, protocol and guidelines specific to the patient care provided.
|Patient assessments were completed within the stipulated timeframe and accessible to all members of the healthcare team. The information was accurate and complete as we had templates of information sheets to guide us and it was shared through the company website, telephones, fax machines.||no||No|
|15||To what degree was the communication among participants adequate for this situation?||Analysis of factors related to communication should include evaluation of verbal, written, electronic communication or the lack thereof. Consider the following in your response, as appropriate:
· The timing of communication of key information
· Misunderstandings related to language/cultural barriers, abbreviations, terminology, etc.
· Proper completion of internal and external hand-off communication
· Involvement of patient, family and/or significant other
|Anytime a patient falls, the supervising nurse is notified immediately, the physician is notified immediately too and the patient’s significant other. The SBAR technique is used to communicate with the doctors and supervisor.||yes||No|
|16||Was this the appropriate physical environment for the processes being carried out for this situation?||Consider processes that proactively manage the patient care environment. This response may correlate to the response in question 6 on a more global scale.
What evaluation tool or method is in place to evaluate process needs and mitigate physical and patient care environmental risks?
How are these process needs addressed organization-wide?
Examples may include, but are not limited to:
· alarm audibility testing
· evaluation of egress points
· patient acuity level and setting of care managed across the continuum,
· preparation of medication outside of pharmacy
|My facility uses only bed alarms for certain patients who are at high risk of falling. Confusion oftentimes lead to falls and frequent monitoring by staff helps avoid this. For example I try to prepare each patient’s medication at the entrance of their room so as to be able to watch them.||no||no|
|17||What systems are in place to identify environmental risks?||Identify environmental risk assessments.
· Does the current environment meet codes, specifications, regulations? Medical Errors: Root Cause Analysis Assignment
· Does staff know how to report environmental risks?
· Was there an environmental risk involved in the event that was not previously identified?
|The facility has to meet certain requirements laid down by the state to ensure patient safety and how to report events. No new environmental risk was identified. And in the case of any new development staff knows to report to maintenance department.||no||no|
|18||What emergency and failure- mode responses have been planned and tested?||Describe variances in expected process due to an actual emergency or failure mode response in connection to the event.
Related to this event, what safety evaluations and drills have been conducted and at what frequency (e.g. mock code blue, rapid response, behavioral emergencies, patient abduction or patient elopement)?
Emergency responses may include, but are not limited to:
· External disaster
· Mass casualty
· Medical emergency
Failure mode responses may include, but are not limited to:
· Computer down time
· Diversion planning
· Facility construction
· Power loss
· Utility issues
|Quarterly fire drills are performed. Safety/ emergency in services are conducted monthly to teach and remind staff how to respond in case of emergencies.||no||no|
|19||How does the organization’s culture support risk reduction?||How does the overall culture encourage change, suggestions and warnings from staff regarding risky situations or problematic areas?
· How does leadership demonstrate the organization’s culture and safety values?
· How does the organization measure culture and safety?
· How does leadership establish methods to identify areas of risk or access employee suggestions for change?
· How are changes implemented?
|The overall culture or management/staff culture welcomes suggestions from staff members regarding patient care and safety. Safety and other changes are measured by questionnaire results.||yes||no|
|20||What are the barriers to communication of potential risk factors?||Describe specific barriers to effective communication among caregivers that have been identified by the organization. For example, residual intimidation or reluctance to report co-worker activity.
Identify the measures being taken to break down barriers (e.g. use of SBAR). If there are no barriers to communication discuss how this is known.
|I have not noticed any barriers to communication. This may be due to the fact that there is a guideline, a form to fill, a recognized protocol for every incident or event.||no||no|
|21||How is the prevention of adverse outcomes communicated as a high priority?||Describe the organization’s adverse outcome procedures and how leadership plays a role within those procedures.||Through delivery of regular in service trainings||yes||no|
|22||How can orientation and in-service training be revised to reduce the risk of such events in the future?||Describe how orientation and ongoing education needs of the staff are evaluated and discuss its relevance to event. (e.g. competencies, critical thinking skills, use of simulation labs, evidence based practice, etc.)||By constantly reevaluating the contents of each in service training to ensure it meets the current learning needs of the staff, frequent competency tests, research and application of evidence based practices||yes||yes|
|23||Was available technology used as intended?||Examples may include, but are not limited to:
· CT scanning equipment
· Electronic charting
· Medication delivery system
· Tele-radiology services
|My facility does partly electronic charting, partly paper charting. Electronic vital signs equipment are also used.||no||no|
|24||How might technology be introduced or redesigned to reduce risk in the future?||Describe any future plans for implementation or redesign. Describe the ideal technology system that can help mitigate potential adverse events in the future.||Complete or full electronic charting which will centralize more patient information for easier access to providers and other healthcare team members.||no||no|
|Action Plan||Organization Plan of Action
Risk Reduction Strategies
|Method: Policy, Education, Audit, Observation & Implementation|
|For each of the findings identified in the analysis as needing an action, indicate the planned action expected, implementation date and associated measure of effectiveness. OR. …||Action Item #1:
Prompt response to call light. Effects of medication. Muscle weakness and confusion.
|If after consideration of such a finding, a decision is made not to implement an associated risk reduction strategy, indicate the rationale for not taking action at this time. Medical Errors: Root Cause Analysis Assignment||Action Item #2:
Rushing to complete tasks because the nurse-patient ratio is high
|Check to be sure that the selected measure will provide data that will permit assessment of the effectiveness of the action.||Action Item #3:
Tight spaces in the room for maneuvering of assistive mobility devices.
|Consider whether pilot testing of a planned improvement should be conducted.||Action Item #4:
Staffing ratio has always been an issue. A nurse has an average of 22 patients and more, a lot of times.
|Improvements to reduce risk should ultimately be implemented in all areas where applicable, not just where the event occurred. Identify where the improvements will be implemented.||Action Item #5:
Revision of orientation and in service training
|Action Item #6:|
|Action Item #7:|
|Action Item #8:|
Álvarez-Barbosa, F., Pozo-Cruz, B., Pozo-Cruz, J., Alfonso, R., Sañudo-Corrales, B., Rogers, E. (2016). Factors Associated with the Risk of Falls of Nursing Home Residents Aged 80 or Older. Rehabilitation nursing. 41(1): 16-25. Database: CINAHL Complete
Alves, A., Freire de Araújo Patrício, A., Fernandes de Albuquerque, K., Duarte, M., Jiovana de Souza, S., Salles de Oliveira, M. (2016). Occurrence of falls among elderly institutionalized: prevalence, causes and consequences. Journal of Research& Fundamental care online. 4376-4386.
Leland, N., Gozalo, P., Teno, J., Mor, V. (2012). Falls in newly admitted nursing home residents: A National study. Journal of the American Geriatrics Society. 60(5): 939-945. Database: Academic Search Complete.
Miller, K., Zylstra, R., Standridge, J. (2000). The Geriatric patient: A Systematic approach to maintaining health. American Family Physician. 61(4):1089-1104.
Zubkoff, L., Neily, J., Quigley, P., Soncrant, C., Yinong, Y., Boar, S., Mills, P. (2016). Virtual breakthrough series, Part 2: Improving fall prevention practices in the Veterans Health Administration. Joint Commission Journal on Quality & Patient Safety. 42(11): 497-500.
Medical Errors: Root Cause Analysis Assignment