Policy Making and Stakeholders

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 patient’s 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 nature should be determined at the spot as soon as the sentinel incident is reported, even if it is verbally conveyed to the supervisor. 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, Unit’s 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, patient’s 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 patient’s 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 hospital’s patient confidentiality policy. It must be well-perceived that patient safety event report is for the organization’s internal workings and must be privileged for PMC’s 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 supervisor’s inbox, waiting to be reviewed by him so that instantaneous actions could be taken to avoid any possible patient safety event or its adverse events.

Procedure for supervisor analysis, 48 hours of notification

After the incident is reported, the supervisor must take action within 48 hours to follow up on the event as soon as possible to avoid traumatic consequences for the concerned family. It has been investigated that the in-hospital baby switches are seriously psychologically shocking for the parents and even hazardous for the newborn’s health as the baby would be breastfed by the wrong mother, leading to transmission of infection (Patient Safety Solutions, 2009).

The follow-up procedure encompasses clicking on the email to obtain patient safety event identification number, clicking on the hospital webpage and clicking on “follow-up,” clicking on the “evaluation” tab for reviewing for any possible accuracies, clocking on “move forward” for editing, and finally sending it to submit. The intranet should be logged out once a click on ‘close’ has been made and the patient safety event has been sent for evaluation to the concerned departments.

Role of Patient Safety Officer

The patient safety officer reviews all the documents to keep an eye on the progress of the sentinel event. The patient safety committee is formulated to analyze the event and find opportunities to remove the possible reasons that caused the event. The committee constitutes of Patient Safety Officer, Chief Medical Officer (or his designee), Chief Nursing Officer (or his designee), Chief Operating Officer (or his designee), AVP Laboratory or his designee), and other administrative personnel if applicable.

The reporting of the patient safety event should be studied to identify the safety issue trends. The regular or periodic reporting of a certain patient safety event should be overseen so that determining the ‘common formats’ should be made convenient for examining the Patient Safety Organization (PSO). The feedback given by PSO should be promptly taken into account for finding the improvement opportunities and even disseminating the feedback to the staff to rectify the workflow processes and procedures.

Depending on the emergency type of the sentinel event, the analysis should take place biweekly or daily to solve the issue promptly. Recommendations of modifications in the processes and procedures to improve the patient safety event and decreasing the chances of occurrence of sentinel event would be studied by the patient safety officer. Moreover, the Board of Directors should be informed of the changes or the possible rectification within the organization’s procedures so that the direction of the plan should be set and approved by the stakeholders.

KEYWORDS

Sentinel

Events

Root cause analysis

References

Hall, L.H., Johnson, J., Watt, I., Tsipa, A. & O’Connor, D.B. (2016). Healthcare staff wellbeing, burnout, and patient safety: A systematic review. PloS One, 11(7). https://doi.org/10.1371/journal.pone.0159015

Josephson, S.A. (2016). Focusing on transitions of care. Clinical Practice, 6(2), 183-189. https://doi.org/10.1212/CPJ.0000000000000207

“Patient Safety Event Reporting.” (n.a.). Provided by the customer

Patient Safety Solutions. (2009, November 17). Switched babies. https://www.patientsafetysolutions.com/docs/November_17_2009_Switched_Babies.htm

“Sentinel event.” (n.a.). Provided by the customer

Strategic Radiology. (n.a.). Patient safety evaluation system (PSES) policies and procedures for root cause systems analysis. Provided by the customer

The Joint Commission. (n.a.). Framework for root cause analysis and corrective actions. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/rca_framework_101017.pdf?db=web&hash=B2B439317A20C3D1982F9FBB94E1724B

Wallace, S.C. (2016). Newborns pose unique identification challenges. Pennsylvania Patient Safety Advisory, 13(2), 42-49.

Appendix

Patient safety events are to be decreased if patient safety is to be maximized within the healthcare industry. The patient safety events that occur and result in death, severe harm or injury, or severe, temporary harm to the patients are critical. The hospitals must not overlook them. The staff at each level must be scrutinized to identify the root cause of such an event for minimizing the number of these events to a greater extent. Root cause analysis for a sentinel event, discharge of an infant to the wrong family (“Sentinel event,” n.a., p.1), would be investigated under the Joint Commission root cause analysis (RCA) framework for helping the Patient Safety Organization (PSO) to analyze the situation deeply within Pikeville Medical Center’s (PMC) medical facilities.

The following table signifies the root cause factors for the chosen sentinel factors: the discharge of an infant to the wrong family (The Joint Commission, n.a., p. 14).

Root Causes Types

Causal Factors/ Root Cause Details

Communication factors

The communication factor that played its part in the sentinel event was the quality of communication during the transition of care. Almost one-fifth of the patients are researched to be victims of medical errors that occur through the adverse event during the transition of care (Josephson, 2016). The process starting from the room where the birth of the newborn takes place, the nurse taking the baby for a bath, dressing and bringing him again to the parent, keeping him at the nursery, taking him for further general checkups, taking him back to the mother for feeding and then finalizing him for the discharge involves various turns and rounds that are critical for switching the babies to the wrong families.

Environmental factors

No environmental factors are involved in the selected sentinel event.

Equipment/ device/ supply/ healthcare IT factors

Health information technology issues such as a display at the wristband against the right family name, labeling with wrong or missing information about the family details, or witching the babies’ names against their original families are possible factors that could be attributed to healthcare IT root causes. The newborn misidentification poses new challenges for systematic patient identification at the hospitals since the IT systems have to be upgraded at each minute level to avoid the misrepresentation of the information of the concerned families (Wallace, 2016).

Task/ process factors

The workflow becomes inefficient or complex when many areas where errors could be involved are part of care transitions. For example, the errors could include taking the baby from the operation room by the primary nurse. After being dressed, it is taken by another nurse to his mother; the identification band has names of the babies with the same last name, the weight of the babies with the same names is not double-checked. Information on the wristband is misrepresented, the names of the babies are right, but the birth parents’ name is wrong, etc.