Instruction: This role-play is based on the Case Study below. You will act as a group of senior leadership officials in a health system. You will assume the roles listed below. All roles may not be filled dependent on the team size. Review the Case Study and Case Study Roles for more background. Complete the Root Cause Analysis Table by identifying the various steps in conducting a root cause analysis using the information (Questions 1-4) and additional resources.

  1. How does the process consider each role’s perspectives regarding risk management?
  2. How does the process influence each role’s ability to make risk management decisions?
  3. What are some inherent conflicts in the team’s roles regarding risk management?
  4. How should the organization resolve differences in perspective regarding risk management?
  5. Use APA Format
  6. List your References in APA format

The template (pages 4-7) is provided as an aid in organizing the steps in a root cause analysis. Not all possibilities and questions will apply in every case, and there may be others that emerge in the analysis. However, all possibilities and questions must be fully considered in your quest for root cause and risk reduction. As an aid to avoiding loose ends, the three columns on the right must be checked off for later reference:

  • “Root cause?” should be answered “Yes” or “No” for each finding. A root cause is typically a finding related to a process or system that has a potential for redesign to reduce risk. If a particular finding is not a root cause, address it later with a “Why?” question. Each finding should be considered for an action and addressed in the action plan.
  • “Ask ‘Why?” should be checked off when reasonable to ask why the finding occurred or did not occur–in other words, to drill down further. Each item must be addressed later in the analysis with a “Why?” question. Any significant findings that are not identified as root causes have roots.

“Take action?” should be checked for any finding that may reasonably be considered for a risk reduction strategy. Each item must be addressed later in the action plan. Write the number of the associated action item on page 3 in the “Take Action?” column for each finding that requires an action.

Case Study

Mr. Johnson is a 55-year old man who had a lesion detected on his right lung during a chest X-ray for possible pneumonia in the veterans’ affairs (VA) clinic. He was seen by a pulmonary specialist in another clinic and agreed to have his lung biopsied. The specialist and nurse told Mr. Johnson there would be little discomfort after the procedure. Therefore, he would not have to stay overnight.

He was admitted to the short stay unit (SSU) early on 11/1/09 to have a biopsy performed on his lung by a radiologist using guided computed tomography (CT) scanning. He was mildly sedated and transported to the radiology department that morning. He also had an intravenous catheter placed, and cardiac and blood pressure monitors were attached. The radiologist was assisted by a radiology resident. The resident’s role was to document the procedure, monitor Mr. Johnson, and learn. The CT scan assisted in locating the lesion. The radiologist pushed a needle through the chest wall into the lung and aspirated tissue to be tested. After the needle was withdrawn, both clinicians noticed an expected complication: a pneumothorax, or air outside the lungs. The pneumothorax was small—10%, and the partially sedated Mr. Johnson did not complain. After an unexpected 15-minute delay, the transport person moved Mr. Johnson back to SSU, and monitors were attached.

In the next 30 minutes, nobody directly checked Mr. Johnson. During that time, the pulse oximeter alarm was activated repeatedly, but Mr. Johnson learned to silence the machine earlier due to so many false alarms. He was surprised that his chest hurt, but did not want to complain. Soon after, the nurse noticed Mr. Johnson silencing the alarm and grimacing. After checking vital signs and looking at the chart, she asked for an order for a chest X-ray, and she called the radiologist. Blood pressure, heart rate, and respiratory rate were all elevated. The radiology notes were difficult to read, and she remembered that the resident usually dictates his or her notes. Chest X-rays now showed a 30% pneumothorax. A chest tube was placed for 3 days, with Mr. Johnson mainly bedridden. After 2 more days of observation and without further treatment, he was able to return home. It was thought that a delay in placing a chest tube might have only slightly worsened the complication of a progressing pneumothorax.

Case Study Roles

  1. Charge Nurse: The charge nurse is responsible for knowing each patient's status, and supervising decision-making and care given to each patient to facilitate quality care. The charge nurse also accepts notification and discusses options for admissions to the unit, to ensure appropriate care may be provided. The charge nurse will assign admission on the basis of each staff member's patient load, and his or her capabilities to facilitate optimal and safe patient care. Maintaining a collaborative relationship with health team members is critical for the charge nurse, for he or she must be aware of everything going on with patients on the unit. If issues arise, the charge nurse must communicate with appropriate departments to provide quality patient care, such as housekeeping, maintenance, operation management, and so forth.
  2. Consulting Physician: The consulting physician provides guidance; provides his or her opinion to the radiologist, resident, staff; and assists in the general care of the patient.
  3. Prescribing Physician: The prescribing physician usually implements instructions for postoperative procedures for the medical staff to follow.

Immediate Actions:

a) Mr. Johnson was cared for with intravenous fluids, pain medications, and watched closely with a cardiac monitor and pulse oximeter.

b) The records kept in the radiology department were copied.

c) The pulse oximeter was sent to clinical engineering for malfunction testing.

d) The facility director was told about the case on 11/2/09.

Other Useful Data:

a) Patients are usually evaluated every 5 minutes after a procedure.

b) The pulse oximeter was found to have no malfunctioning parts.

c) The SSU was a new concept for this facility and Mr. Johnson signed a consent form.

Root Cause Analysis Template

Level of Analysis

/ Questions / Findings / Root
Cause? / Ask
“Why?” / Take
Action
What happened? / Sentinel Event / What are the details of the event?
When did the event occur?
What area or service was affected?
Why did it happen? / The process or activity in which the event occurred / What are the steps in the process? A flow diagram may be helpful.
What were the most proximate factors? / What steps were involved in the event?
Human factors / What human factors were relevant to the outcome?
Equipment factors / How did the equipment performance affect the outcome?
Controllable environmental factors / What factors directly affected the outcome?
Uncontrollable external factors / Are they beyond the organization’s control?
Other / Are there other factors that directly influenced this outcome?
What other areas or services are affected?
Level of Analysis / Questions / Findings / Root
Cause? / Ask
“Why?” / Take
Action
Why did that happen? What systems and processes underlie those proximate factors? / Human resources issues / To what degree are staff properly qualified and competent for their responsibilities?
Common cause variation may lead to special cause variation in dependent processes. / How did staffing compare with ideal levels?
What are the plans for dealing with contingencies that reduce effective staffing levels?
To what degree is staff performance in the processes addressed?
Level of Analysis / Questions / Findings / Root
Cause? / Ask
“Why?” / Take
Action
How mayorientation and in-service training be improved?
Information management issues / To what degree is all necessary information available, accurate, complete, or unambiguous, when needed?
To what degree is communication among participants adequate?
Environmental management issues / To what degree was the physical environment appropriate for the processes?
What systems are in place to identify environmental risks?
What emergency and failure-mode responses have been planned and tested?
Leadership issues:
Corporate culture / To what degree is the culture conducive to risk identification and reduction?
Encouragement of communication / What are the barriers to communicating potential risk factors?
Clear communication of priorities / To what degree is the prevention of adverse outcomes communicated as a high priority? How?
Uncontrollable factors / What maybe done to protect against the effects of these factors?
Action Plan /

Risk Reduction Strategies

/

Measures of Effectiveness

For each finding needing an action, indicate the planned action, implementation date, and associated measure of effectiveness. / Action Item 1:
If, after considering such a finding, a decision is made not to implement an associated risk reduction strategy, indicate the rationale for not taking action. / Action Item 2:
Check that the measure will provide data that permits assessment of the action’s effectiveness. / Action Item 3:
Consider whether pilot testing of a planned improvement mustbe conducted. / Action Item 4:
Improvements to reduce risk mustbe implemented in all areas where applicable, not just where the event occurred. Identify where the improvements will be implemented. / Action Item 5:
Action Item 6:
Action Item 7:
Action Item 8:
Cite any books or articles considered in developing this analysis and action plan:

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