Component  2  Assignment  –  Root  Cause  Analysis  (Inpatient  falls)     Introduction:     Falls  are  a  problem  in  hospitals  with  risks  for  preventable  morbidity  and  mortality  to  patients   who  are  at  risk.  One  study  predicts  the  number  of  falls  in  the  US  resulting  in  injury  by  2020  to   be  over  17  M  with  an  estimated  cost  of  over  $85  B.  Certain  populations,  such  as  the  elderly  in   at  risk  settings  such  as  hospitals  may  be  at  even  higher  risk.  Of  benefit  are  tools  that  can   identify  patients  who  are  at  higher  risk  for  falls  and  their  morbidity  and  mortality,  and  so  one   study,  that  developed  a  screening  tool  and  educational  program  from  published  evidence  to   assess  fall  risk  of  patients.  The  tool  was  piloted,  implemented  and  ultimately  evaluated  to   demonstrate  impact  in       Reference  documents:     Apkon  M.  Understanding  and  preventing  errors.  In  Pediatric  Informatics:  Computer  Applications   in  Child  Health  (ed  CU  Lehmann,  GR  Kim,  KB  Johnson),  Springer  New  York,  2009.  P  369-­‐383.       A  general  overview  of  error  prevention     Currie  L.  Fall  and  Injury  Prevention.  Patient  Safety  and  Quality:  An  Evidence-­‐Based  Handbook   for  Nurses.     Cameron  ID,  Gillespie  LD,  Robertson  MC,  Murray  GR,  Hill  KD,  Cumming  RG,  Kerse  N.  2012.   Interventions  for  preventing  falls  in  older  people  in  care  facilities  and  hospitals.  Cochrane   Database  of  Systematic  Reviews,  2012.  12:  pp.  CD005465-­‐1-­‐CD005465-­‐63     Degelau  J,  Belz  M,  Bungum  L,  Flavin  PL,  Harper  C,  Leys  K,  Lundquist  L,  Webb  B.  Institute  for   Clinical  Systems  Improvement.  Prevention  of  Falls  (Acute  Care).  Updated  April  2012     General  overviews  of  knowledge  on  falls.  These  are  provided  less  for  detailed  reading   than  for  reference  and  for  overview  of  the  problem  and  approaches  to  help  with  the   deliverable.     *Poe  SS,  Cvach  MM,  Gartrell  DG,  Radzik  BR,  Joy  TL.  An  Evidence-­‐based  Approach  to  Fall  Risk   Assessment,  Prevention,  and  Management:  Lessons  Learned.  J.  Nurs  Care  Qual  Vol.  20,  No.  2,   2005,  pp.  107–116.     *Poe  SS,  Cvach  MM,  Dawson  PB,  Straus  H,  Hill  EE.  The  Johns  Hopkins  Fall  Risk  Assessment  Tool   Postimplementation  Evaluation.  J  Nurs  Care  Qual  Vol.  22,  No.  4,  2007,  pp.  293–298.     These  two  articles  are  on  the  Johns  Hopkins  experience  in  developing  a  screening  tool  for   assessing  fall  risk  for  inpatients.     The  Joint  Commission—Sentinel  Event.  URL:   http://www.jointcommission.org/sentinel_event.aspx   The  Joint  Commission  –  Sentinel  Event  Policy  and  Procedures.  URL:   http://www.jointcommission.org/Sentinel_Event_Policy_and_Procedures     The  Joint  Commission  –  Sentinel  Event,  Framework  for  conducting  a  Root  Cause  Analysis  and   Action  Plan  URL:   http://www.jointcommission.org/Framework_for_Conducting_a_Root_Cause_Analysis_and_Ac tion_Plan/     Scenario:     The  Urban  Hospital  Center  (UHC)  Emergency  Department  Observation  Unit  has  been  in   operation  for  six  months  but  recently  had  a  problem  noted  where  the  father  of  one  of  the   members  of  the  Board  of  Trustees,  who  was  taken  to  the  Emergency  Department  for  evaluation   of  an  acute  medical  problem,  was  transferred  to  the  EDOU.  During  the  stay,  he  fell  and   fractured  his  right  femur.  This  event  required  that  he  be  taken  to  the  operating  room  for  setting   and  immobilization  and  the  conversion  of  the  EDOU  visit  to  an  inpatient  admission.  He  tolerates   the  surgery  and  anesthesia  well  without  complications  and  is  transferred  to  the  medical  surgical   floor  for  recuperation.       You  are  the  nurse  manager  for  the  EDOU  and  are  working  with  the  hospital  administrator  for   the  unit  to  determine  what  happened.       Assignment  Deliverable     Part  1:  Outline  a  plan  of  your  investigation  of  the  incident  by  answering  the  following  questions:     1. What  is  the  Joint  Commission,  what  is  its  mission  and  what  does  it  do?   2. What  is  a  Sentinel  Event  according  to  the  Joint  Commission?   3. What  is  required  of  hospitals  when  a  Sentinel  Event  occurs?   4. Is  a  Root  Cause  Analysis  required  for  the  described  scenario?  Why  or  why  not?   5. On  discovery  of  a  Sentinel  Event:   a. Who  needs  to  be  informed?   b. Who  needs  to  be  interviewed?   c. What  questions  need  to  be  asked?   d. What  workflows  need  to  be  reviewed?   e. What  documentation  and  artifacts  require  review?   f. What  is  your  assessment  as  to  what  happened?   g. What  recommendations  would  you  make  to  prevent  this  from  recurring?     h. How  would  you  prioritize  these  recommendations  and  why?   6. Give  one  example  of  the  Person  approach  to  this  RCA  and  one  example  of  the  System   approach  to  the  RCA.  What  are  the  pros  and  cons  of  each?         Part  2:  Given  the  Incident  Report  (C_02_a04_Assignment_Incident_Report.docx)     1. Complete  the  RCA  report  (C_02_a04_Assignment_Form.docx)   2. Ask  any  questions  you  have  to  Dr.  Norgbey  via  the  Discussion  Forum.  Responses  will  be   shared  by  the  class.   3. Given  what  you  have  found  in  your  reading,  the  report  and  the  answers  to  your   questions,  answer  the  three  components  of  an  RCA  for  this  case:   a. What  do  you  think  happened?   b. Why  do  you  think  it  happened?   c. What  can  be  done  to  prevent  it  from  recurring?     Submission  Instructions     There  are  two  deliverables:     1. Part  1  Answers:  Submit  a  single  document  in  MS  Word  or  portable  document  format   (pdf)  with  a  cover  sheet  that  identifies  the  submitter  with  attestations  to  the  Course   Dropbox.  (MS  Word  documents  may  be  converted  to  pdf  in  Word  2007+  by  using:   FileàSave  Asà.pdf)   2. The  form  from  the  Joint  Commission  with  answers  from  their  RCA  to  the  Course   Dropbox.             Urban Hospital Center Emergency Department Observation Unit Inpatient Incident Report (Confidential) Incident Type: INPATIENT FALL Date and Time of Incident: 11/1/2014 00:44 Date Report Filed: 11/1/2014 09:01 Clinical Location: EDOU Patient Bed Number: EDOU-5 Date/Time Admitted to Ward: 10/31/2014 20:00 Did the Incident result in patient death __ Yes _X_No Description of the incident: Patient ID: 123-45-6789 Primary Physician ID: T334223 Primary Nurse ID: N342 Nurse Supervisor ID: NS3433 Reporter ID: NS3443 Date/Time Physician Notified: 11/1/2014 01:30 Pt is a 79 yo WM admitted to the EDOU 10/31/2014 2000 from the ED for continued observation s/p an episode dx’ed as TIA with partial resolution. Pt was admitted and had RN intake and MD workup documented on admission. At 11/1/2014 00:44 pt was found by staff on the floor, unresponsive but breathing near the toilet in the room, with a chair fallen down on the floor next to him. The floor was wet. Pt was connected to IV pole. Pt was unattended prior to finding. On initial report, pt was arousable and when questioned complained of pain in the right leg. When asked what happened, pt responded, “I needed to go to the bathroom, so I got up…I don’t remember anything else, what happened?” Rapid response team was called. RRT assessment: VS: BP 100/60, P: 90 R: 20, T: 38.0 (otic), SaO2 97 Notable hx: Pt admitted for evaluation of TIA Sensorium clear with lapse of memory to the event of fall MSE grossly intact, able to answer questions appropriately. Exam: VSS Patient gown wet, no evidence of blood HEENT: NCAT, PERRLA, TMs intact, NT clear without blood, Teeth present and intact Neck (placed into a stiff collar initially, subsequently cleared) Lungs/Heart: Exam intact without evidence of trauma, no rib tenderness, no pain on inspiration/expiration Abdomen: Normal examination without tenderness or mass GU: No urinary catheter in place Ext upper: grossly intact; LUE with working IV and IVF intact Ext lower: RLE intact; LLE: Thigh intact, lower leg displaced without evidence of open fracture; distal pulses intact; pt c/o pain on touching LLE Neuro: grossly intact on exam Was next of kin notified? Yes No (If no why not?) Resolution of the incident: RRT was contacted on discovery and pt was evaluated to have a LLE fracture. Pt was stabilized per RRT and taken to the intermediate care unit for further evaluation by Orthopedics. Primary Physician was notified 01:30. Pt was taken to the OR by Orthopedics 02:30 for closed reduction of fracture under anesthesia supervision (Details in operative report). Pt tolerated the procedure well and was returned to the inpatient floor for post-op care and discharge planning. RCA Framework Revised 3/21/2013 ROOT CAUSE ANALYSIS AND ACTION PLAN FRAMEWORK TEMPLATE The Joint Commission Root Cause Analysis and Action Plan tool has 24 analysis questions. The following framework is intended to provide a template for answering the analysis questions and aid organizing the steps in a root cause analysis. All possibilities and questions should be fully considered in seeking “root cause(s)” and opportunities for risk reduction. Not all questions will apply in every case and there may be findings that emerge during the course of the analysis. Be sure however to enter a response in the “Root Cause Analysis Findings” field for each question #. For each finding continue to ask “Why?” and drill down further to uncover why parts of the process occurred or didn’t occur when they should have. Significant findings that are not identified as root causes themselves have “roots”. As an aid to avoid “loose ends,” the two columns on the right are provided to 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 relevant to the event is not a root cause, be sure that it is addressed later in the analysis with a “Why?” question such as “Why did it contribute to the likelihood of the event” or “Why did it contribute to the severity of the event?” Each finding that is identified as a root cause should be considered for an action and addressed in the action plan.  “Plan of action” should be answered “Yes” for any finding that can reasonably be considered for a risk reduction strategy. Each item checked in this column should be addressed later in the action plan. Page 1 RCA Framework Revised 3/21/2013 When did the event occur? Date: Day of the week: Time: Detailed Event Description Including Timeline: Diagnosis: Medications: Autopsy Results: Past Medical/Psychiatric History: Page 2 RCA Framework Revised 3/21/2013 # Analysis Question 1 What was the intended process flow? 2 Were there any steps in the process that did not occur as intended? What human factors were relevant to the outcome? 3 4 How did the equipment performance affect the outcome? Prompts Root Cause Analysis Findings Root cause Plan of Action List the relevant process steps as defined by the policy, procedure, protocol, or guidelines in effect at the time of the event. You may need to include multiple processes. Note: The process steps as they occurred in the event will be entered in the next question. Examples of defined process steps may include, but are not limited to:  Site verification protocol  Instrument, sponge, sharps count procedures  Patient identification protocol  Assessment (pain, suicide risk, physical, and psychological) procedures  Fall risk/fall prevention guidelines Explain in detail any deviation from the intended processes listed in Analysis Item #1 above. Discuss staff-related human performance factors that contributed to the event. Examples may include, but are not limited to:  Boredom  Failure to follow established policies/procedures  Fatigue  Inability to focus on task  Inattentional blindness/ confirmation bias  Personal problems  Lack of complex critical thinking skills  Rushing to complete task  Substance abuse  Trust Consider all medical equipment and devices used in the course of patient care, including AED devices, crash carts, suction, oxygen, instruments, monitors, infusion equipment, etc. Page 3 RCA Framework Revised 3/21/2013 # Analysis Question 5 What controllable environmental factors directly affected this outcome? 6 What uncontrollable external factors influenced this outcome? Were there any other factors that directly influenced this outcome? What are the other areas in the organization where this could happen? 7 8 Prompts Root Cause Analysis Findings Root cause Plan of Action In your discussion, provide information on the following, as applicable:  Descriptions of biomedical checks  Availability and condition of equipment  Descriptions of equipment with multiple or removable pieces  Location of equipment and its accessibility to staff and patients  Staff knowledge of or education on equipment, including applicable competencies  Correct calibration, setting, operation of alarms, displays, and controls What environmental factors within the organization’s control affected the outcome? Examples may include, but are not limited to:  Overhead paging that cannot be heard  Safety or security risks  Risks involving activities of visitors  Lighting or space issues The response to this question may be addressed more globally in Question #17.This response should be specific to this event. Identify any factors the organization cannot change that contributed to a breakdown in the internal process, for example natural disasters. List any other factors not yet discussed. List all other areas in which the potential exists for similar circumstances. For example:  Inpatient surgery/outpatient surgery  Inpatient psychiatric care/outpatient psychiatric care Page 4 RCA Framework Revised 3/21/2013 # Analysis Question 9 Was the staff properly qualified and currently competent for their responsibilities at the time of the event? 10 How did actual staffing compare with ideal levels? 11 What is the plan for dealing with staffing contingencies? Prompts Root Cause Analysis Findings Root cause Plan of Action Identification of other areas within the organization that have the potential to impact patient safety in a similar manner. This information will help drive the scope of your action plan. Include information on the following for all staff and providers involved in the event. Comment on the processes in place to ensure staff is competent and qualified. Examples may include but are not limited to:  Orientation/training  Competency assessment (What competencies do the staff have and how do you evaluate them?)  Provider and/or staff scope of practice concerns  Whether the provider was credentialed and privileged for the care and services he or she rendered  The credentialing and privileging policy and procedures  Provider and/or staff performance issues Include ideal staffing ratios and actual staffing ratios along with unit census at the time of the event. Note any unusual circumstance that occurred at this time. What process is used to determine the care area’s staffing ratio, experience level and skill mix? Include information on what the organization does during a staffing crisis, such as call-ins, bad weather or increased patient acuity. Describe the organization’s use of alternative staffing. Examples may include, but are not limited to:  Agency nurses  Cross training Page 5 RCA Framework Revised 3/21/2013 # Analysis Question 12 Were such contingencies a factor in this event? 13 Did staff performance during the event meet expectations? 14 To what degree was all the necessary information available when needed? Accurate? Complete? Unambiguous? 15 To what degree was the communication among participants adequate for this situation? Prompts Root Cause Analysis Findings Root cause Plan of Action  Float pool  Mandatory overtime  PRN pool If alternative staff were used, describe their orientation to the area, verification of competency and environmental familiarity. Describe whether staff performed as expected within or outside of the processes. To what extent was leadership aware of any performance deviations at the time? What proactive surveillance processes are in place for leadership to identify deviations from expected processes? Include omissions in critical thinking and/or performance variance(s) from defined policy, procedure, protocol and guidelines in effect at the time. Discuss whether patient assessments were completed, shared and accessed by members of the treatment team, to include providers, according to the organizational processes. Identify the information systems used during patient care. Discuss to what extent the available patient information (e.g. radiology studies, lab results or medical record) was clear and sufficient to provide an adequate summary of the patient’s condition, treatment and response to treatment. Describe staff utilization and adequacy of policy, procedure, protocol and guidelines specific to the patient care provided. Analysis of factors related to communication should include evaluation of verbal, written, electronic communication or the lack thereof. Consider the following in your response, as appropriate:  The timing of communication of key information Page 6 RCA Framework Revised 3/21/2013 # Analysis Question Prompts Root Cause Analysis Findings Root cause Plan of Action  16 Was this the appropriate physical environment for the processes being carried out for this situation? 17 What systems are in place to identify environmental risks? 18 What emergency and failure- mode responses have been planned and tested? Misunderstandings related to language/cultural barriers, abbreviations, terminology, etc.  Proper completion of internal and external hand-off communication  Involvement of patient, family and/or significant other Consider processes that proactively manage the patient care environment. This response may correlate to the response in question 6 on a more global scale. What evaluation tool or method is in place to evaluate process needs and mitigate physical and patient care environmental risks? How are these process needs addressed organization-wide? Examples may include, but are not limited to:  alarm audibility testing  evaluation of egress points  patient acuity level and setting of care managed across the continuum,  preparation of medication outside of pharmacy Identify environmental risk assessments.  Does the current environment meet codes, specifications, regulations?  Does staff know how to report environmental risks?  Was there an environmental risk involved in the event that was not previously identified? Describe variances in expected process due to an actual emergency or failure mode response in connection to the event. Related to this event, what safety evaluations Page 7 RCA Framework Revised 3/21/2013 # Analysis Question 19 How does the organization’s culture support risk reduction? 20 What are the barriers to communication of potential risk factors? Prompts Root Cause Analysis Findings Root cause Plan of Action and drills have been conducted and at what frequency (e.g. mock code blue, rapid response, behavioral emergencies, patient abduction or patient elopement)? Emergency responses may include, but are not limited to:  Fire  External disaster  Mass casualty  Medical emergency Failure mode responses may include, but are not limited to:  Computer down time  Diversion planning  Facility construction  Power loss  Utility issues How does the overall culture encourage change, suggestions and warnings from staff regarding risky situations or problematic areas?  How does leadership demonstrate the organization’s culture and safety values?  How does the organization measure culture and safety?  How does leadership establish methods to identify areas of risk or access employee suggestions for change?  How are changes implemented? Describe specific barriers to effective communication among caregivers that have been identified by the organization. For example, residual intimidation or reluctance to report co-worker activity. Identify the measures being taken to break Page 8 RCA Framework Revised 3/21/2013 # 21 22 Analysis Question How is the prevention of adverse outcomes communicated as a high priority? How can orientation and in-service training be revised to reduce the risk of such events in the future? 23 Was available technology used as intended? 24 How might technology be introduced or redesigned to reduce risk in the future? Prompts Root Cause Analysis Findings Root cause Plan of Action down barriers (e.g. use of SBAR). If there are no barriers to communication discuss how this is known. Describe the organization’s adverse outcome procedures and how leadership plays a role within those procedures. Describe how orientation and ongoing education needs of the staff are evaluated and discuss its relevance to event. (e.g. competencies, critical thinking skills, use of simulation labs, evidence based practice, etc.) Examples may include, but are not limited to:  CT scanning equipment  Electronic charting  Medication delivery system  Tele-radiology services Describe any future plans for implementation or redesign. Describe the ideal technology system that can help mitigate potential adverse events in the future. Page 9 RCA Framework Revised 3/21/2013 Action Plan Organization Plan of Action Risk Reduction Strategies For each of the findings identified in the analysis as needing an action, indicate the planned action expected, implementation date and associated measure of effectiveness. OR. … If after consideration of such a finding, a decision is made not to implement an associated risk reduction strategy, indicate the rationale for not taking action at this time. Check to be sure that the selected measure will provide data that will permit assessment of the effectiveness of the action. Consider whether pilot testing of a planned improvement should be conducted. Action Item #1: Improvements to reduce risk should ultimately be implemented in all areas where applicable, not just where the event occurred. Identify where the improvements will be implemented. Action Item #5: Position/Title Responsible Party Method: Policy, Education, Audit, Observation & Implementation Action Item #2: Action Item #3: Action Item #4: Action Item #6: Action Item #7: Action Item #8: Page 10 RCA Framework Revised 3/21/2013 Bibliography: Cite all books and journal articles that were considered in developing this root cause analysis and action plan. Page 11
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