Application Quality Improvement Models Organizations Systems, Part

¶ … Application Quality Improvement Models Organizations Systems, Part I Analysis Required Resources Readings Course Text: Applying Quality Management HealthCare: A Systems Approach Review Chapter 9, "Improving Processes Implementing

Root cause analysis

According to Nicolini (2011)

the first step in RCA is identifying the incident to be analyzed. This step requires for the problem or incident to be clearly defined and identified. Identifying the problem will assist in determining what caused the incident and how the incident occurred. In the case study, the mother requested for pain medication, and this was within her right. The nurse performed the request, and it was approved by the pharmacist, but the incident occurred when the nurse did not check the IV line correctly. The nurse confused the infants IV line with the mothers, which resulted in the infant been administered with Morphine. This should be an indicator, and it should be recorded as a fact. This is because the nurse admitted that she might have administered Morphine to the infant instead of the mother.

The second step would be organizing a team that will conduct the RCA. This should be an independent team that will investigate, research, and analyze the incident. This team will be unbiased and will use the information collected to provide solutions and recommendations Siriwardena, 2009.

The third step is studying the work processes. From the case study, it is clear that the systems were fully automated, and the doctor had indicated the mother can be given pain medication upon her request. When the mother requested for the pain medication, the nurse performed the five rights accurately. This is why the medication was authorized by the pharmacist and the correct dosage provided. The hospital did not require physical separation of the infant from the mother, which resulted in the nurse picking up the wrong IV line and tracking its source Cooper, 2009()

The fourth step is collecting the facts. In this step, the RCA team will use the patient charts to collect information regarding the incident been investigated Brown, 2011.

The team will also use investigation, and questionnaires to collect data in order to discover all the facts. In this case, the RCA team interviewed the nurse, the pharmacist, and hospital management. Using the interviews it was discovered as to why the incident occurred. The RCA team also interviewed the Level III nursery staffs were also interviewed in order for them to provide their input in regards to the incident. Some of the information that should be included as facts in this stage is the hypothesis from the nurse, the admission by the nurse she might have injected the IV, and the results from tests conducted at the Level III nursery. The fifth step is searching for causes of the incident. The case study incident is quite clear what caused the nurse to mistake the IV line. If the hospital had a policy that required for the physical separation of patient before administering any medication this incident would have been prevented. The RCA team analyzed the results from the infants test and established that the infant had morphine traces in the urine. This indicated that the infant might have been injected with morphine. The mother was also given a toxicology screen, which indicated she did not have any traces of morphine yet it was assumed she got morphine while she was in recovery.

The sixth step is taking action. The hospital administration arranged for meetings to offer their explanation in regards to the incident and also an apology. The chief nursing officer and the nurse also apologized to the mother for the incident. Training was required immediately for all the nurses. The hospital also established a policy requiring physical separation of patients before medication can be administered. The final step is evaluating the actions taken. Analyzing the actions taken by the hospital would assist to determine if they have been effective in preventing the incident from occurring again. This way the hospital management could make adjustments and other recommendations in case the actions taken have not been effective.

Information gathering

As a team in case there is any missing information, the best method for gathering data would be to use questionnaires, interviews, or analysis of the patient records. Analyzing the patient records would allow the team to establish what happened and why the incident occurred. The patient records would also provide information on the diagnosis or results of any test conducted. Interviews would involve the staffs who were attending to the patient. The interviews should be structured in a manner that allows the staff to provide more information. This way a clear hypothesis can be made. Questionnaires normally involve closed ended questions, but with the option of providing further information on certain questions. This would be used for the management as they might not have time to sit for an interview.

The persons who should participate in the analysis will include the attending nurse, obstetrician, pharmacist, chief nursing officer, risk management staff member, and chief medical officer. These are the critical persons involved in the incident and management of the hospital and their input would assist in the determining the root cause of the incident. The questions to be asked should enable the team to establish how the incident occurred, why it occurred, and the persons involved. Most of the questions will revolve on analyzing the steps each individual took. This will allow the team to understand and have a clear picture of the how the incident occurred. Conducting separate interviews and asking different questions will enable the team to also establish where the fault occurred.

Key insights gained

Using the case study and understanding of the root cause analysis, has allowed the team to establish how it can conduct RCA to a patient suffering from fecal impaction. This scenario would be difficult to establish without proper analysis of the symptoms presented by the patient. The patient could be having diarrhea because the rectum is blocked Brunner & Suddarth, 1986.