Question

A patient at your hospital is sent to cardiology for a routine test. The patient returns without incident, and you document the time and condition of the patient on return to the room. The next day, you are summoned to the unit manager's office, along with the charge nurse and unit secretary. The manager describes how the patient was given a dose of Glucophage the morning of the test. The physician wrote an order to hold the Glucophage for 2 days prior to the test because of contraindications between the medication and the intravenous contrast dye. The manager demands an explanation for the incident because controls are in place because of similar incidents on the unit that should flag the medication, requiring the nurse to hold the medication prior to the test.

A.   Who is responsible for initiating a root cause analysis (RCA)?

B. How would you conduct a root cause analysis to determine the cause of the problem? Who would you include? What is the purpose for conducting the RCA?

C. The hospital has a nonpunitive policy for mistakes and errors. How does this affect the RCA if the cause of the problem is identified as a mistake by the unit secretary?

D. The investigation reveals that there were 12 admits and discharges occurring around the time of the incident, with only one unit secretary. Of the admissions, 10 were attributed to the same physician who ordered the test. The nurse was admitting a complicated patient with multiple needs when the patient left for the procedure. Based on this information, where might the fault lie?

E. What possible suggestions could you make to decrease the possibility of a similar incident?

F.   How did the unit use failure mode and effects analysis?

G.  Which TJC patient safety goal was addressed in this case study?

H.   One of the process problems identified involved nurses transcribing the computer MAR onto a sheet of paper. The nurse then takes the handwritten paper into the medication dispensing room to remove medications. The computer on wheels is too large to take into the small medication room. What is this an example of?

Answer 1

A. The RCA facilitator or program coordinator (Here, the unit manager) has responsibility for presenting the investigation’s findings to the people involved in the incident, ensuring organizational reporting requirements are met, and completing the department’s reporting requirements.

B. Root cause analysis to be split up into following:

Man, Machine, Material, and Method

We will include the staff nurse, Unit secretary, unit manager, IT team, MR team, test team.

The purpose of the RCA is to identify the cause of the error by listing down the possible gaps that had led to the error in all the Cross-functional areas. Superficially this error lies at the unit secretary level but if we dig deeper we will come to know many underlying gaps that led to this error. we should not only target or train unit secretary but to remove the deep-lying root cause such as providing handy mobiles or tablets which can be used while delivering medicines as per physician orders. Also, manpower mapping to be done to assign tasks as per the optimal load to a single unit secretary. RCA will not limit to them but also covers the test personnel to ensure that physicians order to stop Glucophage for 2 days and perform the test.

C. Since the hospital has non-punitive policy RCA will be done without any bias on the unit secretary. Fear will not be present in the employees to an extent to hide critical processes.

D. The root cause lies in the overloading of the unit secretary with 12 patients admissions and 12 patients discharge the same at a time. Along with one more critical patient admission and 1 test given. All the 10 patients admitted have been assigned to the same physician. Manpower management is not efficient which had led to this error. Hospital Management or HR to correct this work overload and also different tasks to be assigned to different personnel.

F. Here’s an overview of the 10 steps to a Process Failure Mode Effects Analysis

STEP 1: Review the process

STEP 2: Brainstorm potential failure modes

STEP 3: List the potential effects of each failure

STEP 4: Assign Severity rankings

STEP 5: Assign Occurrence rankings

STEP 6: Assign Detection rankings

STEP 7: Calculate the RPN(Risk Priority Number)

STEP 8: Develop the action plan

STEP 9: Take action

STEP 10: Calculate the resulting RPN(Risk Priority Number)

G. Improve the safety of using medications. Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other settings. Record the correct information about each patient’s medicines. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home.

NB: I am unable to answer all of your questions due to time limit, but you can still ask in separate questions