Root Cause Analysis Essay Example

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Root Cause Analysis: The unfortunate admission

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The unfortunate admission


Health service providers hold the most crucial roles in the society. They are obligated to take due diligence in their processes to avert the errors, which when they occur subject the clients to costly consequences that include loss of life, and others. Root Cause Analysis (RCA) is an approach of identifying the actual and potential error areas in the healthcare processes and subsequently putting measures that prevent such errors from being experienced. In “the unfortunate admission” case, Jane was admitted for an illness, which justified the immediate action that was taken by the hospital staff. Unfortunately, the patient died on the third day of admission due to a systemic error, which was avoidable, in the hospital’s operations.

To avert the losses in the future, the hospital’s operational system is subjected to a proper RCA, which apart from solving a particular problem that led to the patient’s death; it also examines the primary cause of the problem and, therefore, devises measures to avoid a recurrence. A proper RCA for the system in the case of “the unfortunate admission,” the responsible team needs to determine what happened to the patient before she died, why did the patient die and devise ways to reduce the reappearance of the problem (Mills et al., 2005).

Root cause analysis

Using the Fish-Bone Diagram, the team that comprises of various professionals and research experts aim at the effects and the causes, which contributed to such effects. The Fish-Bone Diagram, which looks like a skeleton of a fish, examines the various effects of certain actions and omissions and subsequently ascertains the causes of such actions and commissions. In Jane’s case, the significant root cause of her death that was overlooked is the negligent discharge of an admitted patient without confirming that all the necessary medical processes had been carried. Prioritization of the causal factors entails ranking all the areas that have actual and possible systemic errors and determining those areas that have higher risks, as well as, those that have lower risks (Mills et al., 2005). Jane’s case exposes numerous systemic errors of varied nature. The patient’s unfortunate death was mostly perpetrated by human error, which was caused by the Grant Thompson, M.D., who did not know how to access the up to date data on the new EHR.

The new EHR did not show the laboratory tests that have not been reported were not reported unless the user clicks the “show pending”. Therefore, the technical inefficiencies in the system rank the second in the causation factors that caused the death of the patient. Ranking third in the causal factors is the organizational issues. Apart from installing the substandard system, the hospital does not train its staff on how to use the new systems that are installed. Had the organization effectively trained Grant Thompson, M.D on how to access the results in the system, the doctor could not have authorized the patient’s discharge pending final lab results.

The technical issues that are depicted in the case are the inability of the psychiatry staff to give out the page number or name of the physician unless a follow up call is done to obtain the same. The lack of the schedule that reminds the doctors on duty to order the examination of individual patients at different times portrays another technical problem. Another technical problem is demonstrated in the lack of record keeping, which prompted the attending staff to telephone the staff who previously examined the patient. The failure of the pharmacy staff to request and receive an order immediately from the attending doctors depicts a technical shortcoming (Mills et al., 2005).

The human issues that can be attributed as the causal factors include the incompetence of the doctors to use the installed systems and the omission by some staff to record the various actions that have been done on the patient. Other human issues are the negligence by some staff who disregards some important due process and the inexperience by some staff, especially the ones on internship sessions. On the other hand, the organizational factors include the lack of competent and effective systems, as well as, disregarding the training of staff on how to use the new systems. Others are management negligence that does not reign on its operational staff and lack of competent logistical apparatus as the ambulances to pick and drop the patients at the appropriate referral facilities (Percarpio et al., 2008).

Potential interventions

The potential technical interventions that could be applied to avert the patient’s death exist. They include the discharging doctor should have asked for help from his peers on how to check the pending lab results, and the proactive action by the pharmacy staff to find out the patient’s order from the attending physician. Others are the attending doctor could procure the computer application that reminds them on the patients’ orders and another is, on suspecting about a particular unusual issue, the attending staff should proactively find out through other means about the actual actions, rather than relying on the records (Percarpio et al., 2008).

On the other hand, the human intervention actions to avert the patient’s death include conducting oneself ethically by ensuring that the patient is discharged on proper and absolute recommendations and the concerned staff should proactively ask to be trained on how to use the installed systems. Other human strategies include the psychiatry staff could find a way of providing the doctor’s name and number even when the system does not allow and ensure that all the patients’ cases are clarified when handing over to other staff on shifts. The potential organizational interventions include putting in place proper system that is user-friendly and training the staff on particular pertinent areas of the system. Others are procuring for the emergency vehicles that are useful in transferring the patients to proper areas in case of need (Mills et al., 2005).

Evidence base for intervention

The effective nursing strategy that is applicable as an intervention strategy in Jane’s case is the Compassionate in practice strategy. The strategy revolves around 6Cs, which are care, compassion, courage, communication, competence and commitment (Santucci, 2004). Applying the 6Cs on Jane’s case, the discharging doctor could demonstrate care if he discharged the patient on objective terms and the staff who first realized that the patient needed emergency care could have demonstrated compassion by arranging alternative urgent transportation of the patient to the hospital. The discharging doctor should have taken time to double check that due process was followed even if it consumed organizational time and resources (Chang et al., 2005). Communication, competence and commitment could have guided Grant Thompson, M.D, to make an objective and confirmed decision of discharging a patient on safe terms. The need for medical staff to be compassionate in handling the patients is echoed by the Compassionate in Practice vision by the UK government, Department of Health nursing, midwifery and care staff (Lindeke & Sieckert, 2005). The vision, which was incorporated in their work culture, reiterated the use of the 6Cs in their daily practice to promote both their profession and ensure that the individuals and communities are protected.

On the other hand, the Great Britain’s Royal College of nursing has incorporated the compassionate practice strategy in its national standards. Being a credible and respected institution in the world, application of The Royal College of nursing standards in every healthcare institution is justifiable (Aycock & Boyle, 2009). The compassionate practice nursing strategy is incorporated in the Democratic Nursing Organization of South Africa strategic plan. The strategic plan draws its theories from wide peer reviewed articles done about the South African case. Moreover, the leading African economy offers guidance on other African countries, which borrow most of its nursing practices from South African medical agencies. In wales, Bevan Health Board, which guides the medical practitioners on the pertinent issues, has adopted the compassionate practice nursing strategy on its guidelines. Dubbed the “Vision and Voice for welsh healthcare,” the report by Bevan Health Board premises its bases on the peer reviewed articles and appropriate quantitative research to verify the same (HORTON‐DEUTSCH & Sherwood, 2008). The compassionate practice nursing strategy has also been embraced by the Canadian Nurses Association, which offers professional and education curriculum, as well as, licensing the registered nurses in Canada. The association is managed and advised by the countries respected nurses and other medical practitioners. All of its guidance to all the interested stakeholders is based on scholarly reports and peer reviewed articles (Abendroth & Flannery, 2006).

The practicing nurses around the world can argue the compassionate practice nursing strategy as the most widely used strategy. In fact, the strategy forms the basis for accepted universal care giving approach in the healthcare systems. Therefore, the compassionate practice, which is guided by the 6Cs values, could have been an appropriate strategy to avert the errors that caused the patient’s death in “the unfortunate admission case.” The priority causation factors in the case are human based, which could be removed or minimized through the application of the compassionate practice strategy. The values that guide the strategy are holistic and useful in preventing all other technical and organizational issues in the RCA (Lindeke & Sieckert, 2005).


Appropriate and periodic RCA in the health care institutions is a crucial tool to address the issues that are pertinent to the system. The issues are drawn from technical, human and organizational aspects in the healthcare context. However, RCA has enabled the organizations around the world to determine the root cause of their problems, thus solve such issues effectively. Apart from dealing with the symptoms of a problem, RCA also goes further to address the root causes of the issues that are experienced. Jane’s case in “the unfortunate admission,” presents the various systemic errors that are inherent in the healthcare organizations. Human, technical and organizational issues, rank in the same order as the causation factors of the patient’s death.

Intervention measures, which reduce the severity of the problem, are also prioritized about human, technical and organizational measures. Fish-Bone Diagram is the appropriate RCA method for the Jane’s case (Chang et al., 2005). The method examines the effects and causes of such effects, which suits the nature of issues that are drawn from that particular healthcare set up. Application of the Compassionate Practice nursing strategy to address proactively the issues that are identified in the case will achieve effective results. The efficacy and justification of the Compassionate Practice nursing strategy operate on the six basic values that are holistic, therefore, able to address the pertinent issues before they happen. Moreover, the Compassionate Practice strategy is applicable in virtually all the healthcare institutions around the world, hence, making the strategy credible and reliable (Abendroth & Flannery, 2006).


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