Root Cause Analysis and Quality Improvement in Healthcare: Addressing Never Events

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Root Cause Analysis and Quality Improvement in Healthcare: AddressingNever EventsConduct aRoot Cause Analysis (RCA)of anever eventin a healthcare setting, focusing onidentifying system failures and human errors that contributed to the adverse outcome. UsingKurt Lewin’s Change Management Theory, propose animprovement planto prevent similarincidents in the future. Additionally, applyFailure Modes and Effects Analysis (FMEA)toassess the risks associated with the current process and recommend improvements.Your response should be1,500–2,000 wordsand must include:•A detailedRoot Cause Analysis (RCA)identifying key contributing factors.•An explanation oferrors or hazardsthat led to the event.•A structuredimprovement planbased on Lewin’s Change Management Theory.•An application ofFailure Modes and Effects Analysis (FMEA)to evaluate risks andsuggest process improvements.•Proper citations and references followingAPA format.

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RTT1 Task 2Never events are serious medical errors that are often preventable. When such events transpire, itis necessary to fully assess the situation so that these errors can beprevented in the future. Rootcause analysis (RCA) is a tool employed by healthcare facilities to analyze adverse events andthe systems that lead to them.A. Root Cause Analysis“A central tenet of RCA is to identify underlying problems that increase the likelihood of errorswhile avoiding the trap of focusing on mistakes by individuals” (AHRQ, 2012). The emphasis ofRCA is on error prevention. It is a structured process of gathering data regarding the event,analyzing the information, and finding solutions to the problems to prevent reoccurrences. Ateam consisting of the charge nurse, a physician, a respiratory therapist, a pharmacist, hospitaladministrators, and patients not involved in the case is assembled to work through the process.The team begins by interviewing patients and staff involved to gather as much vital informationas possible. Once all necessary information is compiled, the team works together to get to theroot(s) of the problem.In the case of Mr. B, there were multiple issues that led to the adverse event as opposed to oneroot problem. In the process of defining the problem, several causal factors were identified. Theerror was a result of both facility and human error. Mr. B, a67-year-old patient, presented to thesmall, six-room, rural hospital ED due to severe pain in his left hip following a fall. In his questfor care, he came across some hurdles that eventually led to his death. Amongst one of the manyissues that led to complications was the fact that the hospital was short staffed with only one RN,Nurse J., and one LVN on shift. There was also only one ED physician, Dr. T. At the time of Mr.B’s arrival, two other patients were being cared for. As Mr. B was being treated, a patient thatwas in respiratory distress was being admitted. Meanwhile, the two patients that had been seenearlier were awaiting discharge instructions and the ED waiting room had also become muchbusier. There was additional backup staff present (including a respiratory therapist) that couldhave been called upon for help, yet they never were. The charge nurse or nurse supervisor couldhave stepped in at this point to provide additional help. A lack of present nursing staff andsupport can lead to unfavorable patient outcomes, as is the case with Mr. B. Additionally, thestaff on duty could have lacked training regarding protocols or their training could have been outof date.

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