Introduction
Root Cause Analysis (RCA) is a problem-solving method that identifies the origin of an occurrence or a problem (Shaqdan, Aran, Daftari & Abujudah, 2014). In the healthcare setting, RCA refers to investigations carried out to probe events considered adverse. People with expertise in the issue or area being investigated carry out the RCA (Ramstrom & Bratie 2006). Ramstrom and Bratie (2006) noted that the people carrying out the investigation form a team that comprises the members who were not involved with the error under investigation.
The main reason for carrying out an RCA is to remove the problem causal factor to achieve a beneficial outcome. Corrigan and Donaldson (2000) noted that the primary goal of RCA is to establish what, how and why the problem happened. RCA determines measures that are necessary to prevent a recurrence of a problem. It is carried out in case of a problem arises in the healthcare setting in relation to a mishap in treatments such as wrong diagnosis or medication. For example, if a wrong order is written, RCA does not concentrate on who wrote the order but goes further to assess the environment under which the order was written.
Incident
The incident involved a 65-year-old man suffering from atrial fibrillation, chronic renal insufficiency, and lung cancer. The patient was admitted to the Emergency Department (ED) suffering from shortness of breath. The patient underwent intubation and shortly became hypotensive. Vasopressin and phenylephrine supported blood pressure in the resuscitation process. After some time, phenylephrine was substituted with norepinephrine in the resuscitation process. After some tests had been carried out, the norepinephrine was weaned rapidly, and the patient was left on vasopressin. The main incident was the discovery that the patient was on 0.4 units/min of vasopressin instead of 0.04 units/min (Flanders & Saint, 2005).
Investigation of the Problem
I agree that the problem should be investigated. After the vasopressin was discontinued, and the saturation of oxygen and SVR was adjusted. The treatment was continued using antibiotics, and there were no reported major incidents. Though it is arguable that the overdose did not alter the recovery process of the old man, it is worth noting that the overdose was a risk to his life. The Joint Commission mandates the health facilities to apply RCA to analyze sentinel events. According Utah Administrative Code R380-200-3, mandates health facilities a to report sentinel events that risk the safety and life of patients (Utah Administrative Code, 2013). Medication error is one of the listed events that qualify to report. The incident of overdose with vasopressin qualifies as a care management event that relates to medication error. The RCA on the incident will be in line with the Adverse Health Reporting Law enacted in 2003. The law mandates health facilities to disclose the reportable dangerous events and subsequently publish the events and provide the corrective measures that have been taken (Kohn, Corrigan, Donaldson, 2000).
In addition to the legislative framework, Rosenthal (2007) pointed that the main reason for carrying out an RCA is to establish systematic problems that led to the problem. The analysis entails investigating the environment in which the problem occurred and putting in place measures so that the problem is not repeated. Thus, the investigation must ensure that crucial data is gathered and analyzed to determine what led to the overdose. In case the error was a systematic, the systems are realigned to prevent a repetition of the occurrence in the future.
Goals and Limitations of RCA
The primary goal of RCA is to prevent an occurrence of future harm by eliminating underlying error (Shaqdan, Aran, Daftari & Abujudah, 2014). The framework design for RCA is based on the idea that a solution to a problem is not based on solving the problem but ensuring that a preventive measure is established. RCA avoids the treatment of the symptom and focuses on healing the contributing factor to the problems. Flanders and Saint (2005) stipulated that the main goal of RCA is identifying what led to a problem, how the problem occurred and why the problem was not detected. The analysis findings help to devise appropriate actions to ensure that the problem does not recur. Shaqdan, Aran, Daftari and Abujudah (2014) noted that RCA focuses on the root causes of a problem in an evidence-backed process.
The effectiveness of RCA is determined by the quality that is injected in the analysis process (Flink, Chevalier & Ruperto, 2005). Despite the critical role played by RCA, there is inadequate data that supports RCA effectiveness. The effectiveness of RCA depends on the expertise team carrying out the investigation. The effectiveness of the RCA can be compromised by the level of expertise in the team. In addition, occurrence of an event directs the RCA investigations; a single source error may lead to the investigation. Hence, RCA is bound to leaving out a situation that is more complex in the investigation of the single cause (Shaqdan, Aran, Daftari & Abujudah, 2014). Effectiveness of RCA depends on precise identification and description of events leading to the problem. RCA is also open to personal bias in which an individuals involved may not be cooperative in identification and description of the problem (Shaqdan, Aran, Daftari & Abujudah, 2014). The bias mainly results in instances where the expert team does not have effective problem statement prior to the analysis.
RCA Steps
RCA should result in identifications of changes by redesigning or designing new systems. According to Ramstrom and Bratie (2006), an effective RCA has the following basic steps:
- Gathering the facts that relate to the incident: The process relies on interviews and timelines to collect the initial information that help in moving from a special cause to a common cause.
- Understanding the problem: The step entails analyzing the information to internalize what happened.
- Root cause identification: The step requires probing into the system and the work environment to determine shortcoming or weaknesses within the system that led to the problem.
- Designing of a risk reduction plan: After the cause of the problem is identified, a plan for preventing future risks is developed. The phase entails redesigning of the system or putting in place a new system.
- Evaluation, this step involves assessing the developed plan or design to ensure that it is efficient and risk aversive.
Conclusion
RCA entails an investigation process aimed at identifying the root cause of problem. RCA analysis identifies the cause and designs measures to deter repeat of the problem. RCA is a system-based process that does not focus on individual doings. The main goal of RCA is to ensure that an in-depth fact finding process is applied to answer why, how, why and what questions. RCA is credited for improving the safety of patients. However, RCA is open to limitations, which can be solved by adhering to bias-free analysis steps that focus on the system rather than the individuals.
References
Flanders, A. & Saint, S. (2005). Getting the root of the matter. Rockville, MD: Agency for Healthcare Research and Quality. Web.
Flink, E., Chevalier, C. & Ruperto, D. (2005). Lessons learnt from the evolution of the mandatory adverse event reporting system. In advances in patient safety. Rockville, MD: Agency for Healthcare Research and Quality.
Kohn, L., Corrigan, J. & Donaldson, M. (2000). Building a safer health system. Washington, DC: National Academy Press.
Ramstrom, B, & Bratie, S. (2006). Root cause analysis: A tool for improvement. North Darkota: North Dakota Health Care Review, Inc. Web.
Rosenthal, J. (2007). Advancing patient safety through state reporting systems. Rockville, MD: Agency for Healthcare Research and Quality. Web.
Shaqdan, K., Aran, S., Daftari, B., & Abujudeh, H. (2014). Root cause analysis and health failure mode and effect analysis: Two leading techniques in health care quality assessment. Journal of Radiology, 11 (6), 572-579.
Utah Administrative Code. (2013). Rule R380-200, patient safety sentinel event reporting. Patient safety Initiative. Web.