Root Cause Analysis Policy

POLICY

In the furtherance of achieving the goal of improvement in patient safety and its quality, it is the policy of Pikeville Medical Center (PMC) to make use of the Patient Safety Evaluation System (PSES) to collect, analyze, and submitting information about patient safety events to a Patient Safety Organization (PSO). The specific patient safety event for addressing the sentinel event of discharge of an infant to the wrong family should be scrutinized with quality surveillance for deeply probing into the actual or perceived issues within PMC facilities. The reporting of patient safety events, particularly the sentinel event of switching of newborns, is obligatory and encouraged.

The policy for reporting the patient safety event, particularly the selected sentinel event of discharge of the infant to the wrong family, should be reported to the hospital staff and facilities so that surveillance methods could be launched for prompt detection of the actual event and the relevant perceived issues. The processes and workflows of the concerned sentinel event should be improved so that human behavior should be modified and errors should be reduced for maximum patient safety (Strategic Radiology, n.a., p. 4).

DEFINITIONS

Sentinel event: A sentinel event is one in which patient safety is compromised, not necessarily due to natural reasons, including the patients illness, but may result in the following:

Death

Permanent harm

Severe, temporary harm

Severe, temporary harm: Severe, temporary harm is considered critical when its effects are life-threatening and last for a limited time. The severe, temporary harm caused by the sentinel event like the discharge of the wrong newborn to the family would cause severe psychological torment. The prolonged time for which the family would be under stress would cause serious medical conditions that would require a higher level of medical care.

Adverse event: An adverse event is one that resulted in causing harm to the patient.

Root cause analysis: An analysis is a comprehensive and systematic review of the problem that occurred within an organization (see Appendix). The framework is designed with the inclusion of 24 questions so that the assessment of the event must comprehensively take place.

PROCEDURES

Staff

The incident that involves a patient must be reported through online means so that the directly involved departments and staff should be contacted immediately (Patient Safety Event Reporting, n.a.). The urgency of

Sentinel Event Policy should be followed for sentinel events like a change of the newborn bay and discharging him to the wrong family. The responsibility then lies on the shoulders of the supervisor to communicate the event to the House Manager, Chief Nursing Officer (CNO), Assistant Vice President (VP) of Nursing, Units Director, Chief Regulatory Officer (CRO), and Patient Safety Officer.

The patient safety event report should be completed immediately, preferably by the end of the shift, so that the importunity of the sentinel event must be addressed. All the pertinent data such as staff involved in handling the newborn information and the transference of the newborn from one section of the hospital to another till the newborn was delivered to his mother should be included in the report. The facts should be stated clearly and concisely to avoid any doubtful information. Personal opinions, inessential comments, and assumptions should abstain. According to the disclosure guidelines, facts about the patient safety event, physician notifications, patient interventions, patients response, and revelation should be included in the medical record and document. The reference of the patient safety report should not be mentioned in the patients medical record.

Additionally, it should be communicated to all staff members that patient safety event report is confidential and only for use within the organization. It should not be discussed in front of the hospital staff or victors for adhering to the hospitals patient confidentiality policy. It must be well-perceived that patient safety event report is for the organizations internal workings and must be privileged for PMCs internal use.

Patient Safety Event Reporting System

The event reporting system would include accessing the hospital webpage, logging in, and clicking on the report an event tab; the required fields of the next web page asking about the incident that took place would be filled thoroughly, double-checking the entered information for any corrections, and clicking on submit.

After the incident is reported through the website and intranet, the follow-up procedures could be undertaken the next day immediately. If the weekend intervenes, Monday should be the next immediate day for taking an instant review of the issue. An email directly clicks on into the supervisors inbox, waiting to be reviewed by him so that instantaneous actions could…