Patient safety event reporting systems are paramount in hospitals as a fraction of the attempts to detect and prevent the patients’ problems. Incident reporting is used as a safety tool for voluntary patients. The personnel involved in such events provide full information to the inquiry team. Some state health codes command that hospitals and nursing amenities must investigate the occurrences regarding patient care. In addition to that, such codes require that certain events must be reported as prescribed by the regulations. Reportable occurrences often include those events that have lead to a patient’s severe hurt or death. Based on a case incident, reports should be placed in the medical record and directed to the guidance for lawful advice. This would help prevent discovery on the basis of client-attorney privilege. In some states, the court would not permit incident reports to be discovered, whereas others would do so. This paper discusses the Root Cause Analysis as the healthcare tool, which determines a patients’ problems and prevents them from reoccurring in the future.
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What is RCA? When it is used?
RCA is a broad and orderly method of identifying the spaces in hospital structures and the processes of the health care that may not instantly be noticed; and which may have added to the happening of an incident. The RCA targets the structures and procedures, and not personal performances. It does extensive checking for the underlying supporting agents and the main causes. The RCA recognizes variations that would be needed to advance the systems and processes to stop re-happening of the same episodes. Lastly, RCA finds safe and adequate methods to provide the patient’s care. The use of the RCA builds suggestions and procedures for organizations. Therefore, RCA minimizes the danger of sentinel events’ occurrences in the future. The RCA has answers for questions like what has occurred, why it has occurred, and what should be done to prevent it the next time. Investigations about RCA are carried out by multi-disciplinary squads. These teams inquire about the main cause of the episode and recommend approaches to stop such occurrences in the future. A root cause analysis should be performed at the time a mistake or a variance has happened. Failure to do so, some crucial information might not be reached. All personnel involved in the error ought to be present in the analysis to avoid dilution of facts (Patient Safety sentinel event, 2011).
Case study: clarification of the problem that might stimulate RCA.
The root cause analysis was triggered by the wrong identification and treatment of the two patients. It indicated that the two patients were under the wrong medication as a result of wrong identification by the personnel. It also indicated that there might have been such mistakes in the previous, and they were likely to be repeated in the future. The application of RCA was needed to prevent such situations from re-occurring in the future (Hall, 2008).
Investigation of the problem
Once a problem has occurred, it is needed to be assessed, evaluated, and analyzed for counteractive action. The frequency of occurrence of that event should be established. All these events seek to help determine the source of a problem. The likely recommendations for the problem are made to prevent further re-occurrence of that event. In this regard, problem investigation is important because it reveals the unknown sentinel events so that appropriate measures can be taken to prevent future occurrences. In addition to that, when the investigation is not done, it means the healthcare systems would not be performance efficient. This means that the healthcare workers would be reluctant to perfect their work resulting in poor service delivery to the patients. The RCA helps the healthcare workers adhere to their code of ethics because they would not risk causing an injury or death, which would trigger investigations. Lastly, investigations equip the healthcare teams with the procedures of handling problems.
Purposes and drawbacks of RCA
The RCA concentrates on the problems, causes, and impacts of a problem. This approach is impractical because various problems take various shapes from diverse standpoints. What is observed as a problem for one group is not automatically observed as the problem to the other group; therefore, this would result in a disagreement. More so, if the stronger group succeeds the argument, the result would be based on the problem as observed by the stronger group. This creates new problems.
The RAC will be a success in the problem management if all the concerned functionaries will provide the necessary support. The success of the RCA program in the problem management is single-minded by the policy of the company in the management of risks, the approach of the investigator and the method adopted, and information at hand. If all these elements are not strictly followed, the RCA will fail at the initial stage. Another problem of RAC is its linear postulations, which give room for the increased possibility of errors.
There is also the occurrence of the cause and the effect of association, which makes investigation difficult and unreliable. Lastly, the system can be disintegrated into sections and every part is analyzed independently (Limitations of Root Cause Analysis, 2001). The goal of RCA is to study from undesirable episodes and stop them from happening in the future. RCA also helps the medical personnel to study and improve on the effectiveness of RCA usage in the health care setting. It makes the staff adhere to its roles with a lot of responsibility keeping in mind that they would be answerable for any offense committed on duty. Lastly, RCA helps to reduce and alleviate medical errors by identifying problems and implementing solutions to improve patient safety.
Steps to perform an RCA
A small operational team is chosen to spot the occurrence for analysis. Then, a team is prepared to perform the RCA, and it concurs in terms of reference. It studies the processes and concurs on the methods of collecting evidence. This team collects the details by questioning, arguing, and securitizing the evidence collected. This team does research on the causes of the problem and outlines the suggestions for future improvement. An action is taken to alleviate the problem. Lastly, the action employed is evaluated to determine its value in problem resolution (Bowie et al, 2013).
The RCA system is a necessary tool in a health care setting. This is because it enables the medical personnel to formulate the source of a problem. The possible actions are suggested to prevent the problem’s future re-occurrence. Therefore, this tool enables the health care teams to adhere to their responsibilities for they would be held responsible for any unethical conduct. As a result, many lives of patients would be saved. However, this system has some limitations, which would lead to the manipulation of the outcomes of the problems. This indicates that, at times, such systems might lead to wrong ways of handling problems.
Bowie et al (2013). The seven steps for root cause analysis (RCA) team investigation detail: Table 1. Web.
Hall, L.W. (2008) Advancing Excellence in Healthcare: Mistaken Identity Case. Web.
Limitations of root Cause Analysis (2001). Web.
Patient Safety sentinel event (2011). Web.