A patient at your hospital is sent to cardiology department 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 wants an explanation for the incident because controls are in place due to similar incidents on the unit, that should flag the medication, requiring the nurse to hold the medication prior to the test. Use the Nursing Today textbook for your responses and cite reference:
1. What is a root cause analysis (RCA) and who is responsible to complete the RCA in this case?
2. How would a root cause analysis be conducted to determine the cause of the problem? Who would you include?
3. 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?
4. Which TJC patient safety goal was addressed in this case study?
Solution
- Root Cause Analysis (RCA):
- A root cause analysis (RCA) is a systematic process used to identify the underlying causes of adverse events or near misses in healthcare settings. It aims to uncover the contributing factors that led to the incident rather than focusing solely on the immediate actions or individuals involved.
- In this case, the responsibility to complete the RCA would likely fall on a multidisciplinary team comprising representatives from various roles involved in patient care, such as nurses, physicians, pharmacists, and unit secretaries, under the guidance of hospital management or quality improvement personnel.
- Conducting the RCA:
- The RCA process typically involves several steps, including gathering data, identifying contributing factors, determining root causes, and developing corrective actions to prevent recurrence.
- In this scenario, the RCA team would review the patient’s medical records, medication orders, nursing documentation, and any relevant policies or protocols related to medication administration and test preparation.
- The team would include individuals directly involved in the incident (e.g., nurse who administered the medication, unit secretary who failed to flag the medication order), as well as other staff members who may provide insights into system failures or breakdowns (e.g., charge nurse, pharmacy staff).
- Nonpunitive Policy and RCA:
- A nonpunitive policy for mistakes and errors promotes a culture of transparency, accountability, and learning from adverse events without fear of retribution or blame.
- In the context of conducting an RCA, a nonpunitive approach encourages open communication and collaboration among team members, facilitating the identification of root causes and implementation of effective corrective actions.
- If the cause of the problem is identified as a mistake by the unit secretary, the focus would be on understanding why the mistake occurred and identifying system-level factors (e.g., inadequate training, unclear procedures) that may have contributed to the error, rather than assigning blame to the individual.
- TJC Patient Safety Goal:
- The patient safety goal addressed in this case study relates to medication management and patient safety. Specifically, it aligns with The Joint Commission’s (TJC) goal to reduce the risk of harm associated with the use of medications, which includes ensuring the safe use of high-alert medications and implementing processes to prevent medication errors.