Root cause analysis of case study

¶ … health care environment, the complexities and variabilities of the human condition, when combined with individuals, stress, environmental events, and general work issues has the potential for negative effects. These effects may be from human or mechanical error, or simply the lack of control we hold over biological systems. Using root cause investigative procedures, a determination can be made in a relatively detailed manner what events, no matter how unlikely, occurred to cause the failure. A thorough investigation into these causes is necessary in order to prevent similar occurrences. The basic methodology can be used in numerous ways: in business, education, and in medicine. In most cases, however, there are multiple approaches to resolution; and often require difference levels of resources to solve (Latino, 2006).

In the medical scenario under review, Mr. B, a 67-year-old patient with a history of impaired glucose tolerance, prostate cancer, and chronic back pain, is admitted for extreme pain in his left leg. Because of his tolerance to the oxycodone for his back pain, it was quite difficult to get him sedated. Due to the ER becoming quite busy, Mr. B was placed in a room and stabilized, but had to have his alarm reset because of a low O2 saturation level. Within 10 minutes of resetting, Mr. B's son alerts the nurse that something is wrong. A STAT CODE is called, and Mr. B is intubated, defibrillated and given vasopressors. After 30 minutes of interventions, the ECG returns to normal, but the patient remains dependent upon the ventilator. He is transported to an advanced care facility where, in 7 days, is determined to be brain dead and, upon the family's request, life support is removed.

Looking at Mr. B's situation, we can find several potential causations for his bodily reaction: drug interaction, excessive use of pain medication to allow for procedure, lack of optimal monitoring, and potential misreading of severity of symptoms:

Issue

Tactics

Strategic

Potential Results

Pain Meds

Diazepam, Hydromorphone

Needed to get patient sufficiently relaxed and mobile for manipulation of leg

Oxycodone has had potentially negative and life-threatening interaction's with diazepam, and when combined with morphine products is actually quite dangerous (Drug Interactions Between Oxycodone and Diazapam, 2011)

Supplemental O2

Not given

Physician saw no need

Supplemental O2 might have mitigated some of the combination effects of the three pain meds.

ECG/Respiration Monitor

Not used

Physician saw no need

Because of the previous health history, ECG and Respiration monitoring were desirous

Time Management

Busy ER

Staffing

Staff cannot control cases or number of patients; technological monitoring might have saved time in this case; as would have more careful realization about drug interaction.

Part 2 -- Change Theory -- at its most basic level, change theory takes a situation and changes it so that the results received are not repeated. There are actually a few relatively easy issues that would contribute to the mitigation of this scenario:

Change the approach to pharmaceutical combination -- a combination of hydrocodone, diazepam, and oxycodone was the cocktail that contributed to the death of Heath Ledger, and was very well publicized nationally. In addition, most physicians should be aware of the potentials for drop in BP and respiratory failure. Diligence would be called for regarding giving any pain killers to patients who are on medium to high doses of oxycodone.

Change the approach to electronic monitoring -- as the ER became busier, electronic monitoring of patient would seem logical. Staff cannot be in four places at once; but additional monitoring would have likely caused enough alarm that resuscitation could begin earlier; especially after first warning.

Change the approach to patient history issue; prostate cancer and chronic back pain typically require numerous medications, physician should constantly be aware of interactions within new patients (Tiffany and Lutjens, 1998).

Part 3- Failure Mode and Effect Analysis -- a procedure to analyze system failures, or likelihood of said failures. In this case, because the patient was removed from life-support after being brain dead, enough issues warranted a FMEA committee.

a. Committee -- Attending physician and at least one attending nurse from shift; head physician of HR; ER administrator; representative from HR; representative from Legal; Union representative (if appropriate); PR representative; potentially GP depending on hospital relationship and legal vulnerability.

b. Testing of interventions -- likely establishment of at least two new protocols would be put in place; 1) heightened diligence and/or special considerations for certain pharmaceutical combinations with concurrent educational seminars and/or training sessions; 2) additional monitoring criteria based on patient history, combination of symptoms, severity of treatment. Impossible to do double blind studies on these implications, because a repeat of the action is not wanted; but using case analysis and review, potential negative outcomes could still be tested appropriately.

c. Pre-Steps for FMEA Preparation:

a. Collection and analysis of patient records during ER visit.

b. Collection and analysis of patient file from GP or previous hospital visits.

c. Log of staff, patients, and responsibilities for shift (Resource log allocation study).

d. Notarized statements from all involved in the case.

e. Any test results done white in the ER; if autopsied, any quantitative test results.

f. Physicians and Nurses from ER meet to fill out a FMEA worksheet to help guide committee through longitudinal/chronological issues:, ex:

Function

Failure

Mode

Effects

S

(Severity

Rating)

Causes

O

(Occurrence

Rating)

Current

Controls

D

(Detection Rating)

RPN

(Risk

Priority

Number)

Reccom.

Actions

Res.

Target

Completion Date

Action Taken

What was done for patient, details and time?

What failed? When?

What effects.

Scale 1-10, 10 highest

Identification

How often?

Steps in place now

How are issues detected?

Overall risk priority in similar cases

Step-by-Step recomm.

Who is Resp.

Tactics

(Bluvband and Grabov, 2010)

d. FMEA Steps:

1. Severity -- Determine failure modes based on functional requirements and effects. Severity in this case was drug combination and lack of proper monitoring based on history. Use quantifiable methods, not qualitative. Let facts speak, not suppositions.

2. Occurrence -- Based on a chronological timeline, when did the issues seem to occur that caused the failure; was this a small window (less than 10 minutes) in which patient might have recovered had appropriate monitoring happened? If ER had not been busy, would a nurse have caught issue sooner?