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Root Cause Analysis of the Death of Mr. B

RootCause Analysis of the Death of Mr. B

RootCause Analysis

Theroot cause analysis is a tool that hospitals utilize when they wantto determine the causes, errors or hazards that led to a certainundesirable event. The Joint Commission defines a root cause analysisas the process by which factors that lead to a certain sentinel eventare identified. A root cause analysis places a focus on a system inthe hospital, and not just individuals and their performance. A rootcause analysis identifies areas in these analyzed systems wherepossible improvements can be introduced and implemented. This wouldbe in an effort to reduce the probability of the undesired sentinelevent occurring again in the future. The root cause analysis can alsoshow where opportunities for improving the system are lacking(Latino, 2015). A major benefit of this analysis is that by improvingthe system and minimizing the errors that it is vulnerable to, thepotential for the occurrence of human error is greatly reduced (Rootcause analysis, 2013). This paper will look at application of theRoot Cause Analysis for patient B.

Inthe scenario where the death of Mr. B is observed, several causativefactors can be attributed to leading to this unfortunate event. Thecausative factors include:

  1. Lack of continual monitoring of the patient’s vital signs

  2. Poor sedation protocol training and monitoring

  3. Understaffing

  4. Negligence and inadequate monitoring.

Thefirst causative factor is the nurses’ failure to continuallymonitor the vital signs of Mr. B, thereby providing the necessarysupportive measures accordingly. The second causative factor is thata wrong drug was chosen for sedation of the patient. Mr. B shouldhave been administered to moderate sedation, which would enable himmaintain respiratory integrity as an independent airway would havebeen maintained. However, hydromorphine was used, which leads tosevere sedation. This led to depressed respirations, and it was alsoseen to cause respiratory distress in other patients. It is highlysuspected that this sedation is what could have led to Mr. Bdeveloping respiratory distress. The third causative factor isunderstaffing. The emergency department in this hospital had sixrooms. To cater to the demand of services in these rooms, thedepartment had two nurses (one LPN and one RN), a single ER MD and asecretary. This made it very difficult to implement the personalizedmonitoring of Mr. B, as the LPN and RN were both engaged in receivingpatients as well as discharging others. Moreover, it is highlyinappropriate for an LPN to work in the emergency department. This isbecause this department requires critical and advanced thinking andreasoning skills, which an LPN may very likely come short of. Finallyanother causative factor can be viewed to be negligence. Mr. B wasleft unattended to even though he was unconscious. Even though he wasunder machine support, the only company he had was his son. The RNcould not even heed to the alarm from Mr. B, as he was busy admittinganother patient going through respiratory distress. The hospital wassupposed to ensure that at least one nurse is placed to attend to Mr.B, and the nurse most suitable to do this was nurse J. Furthermore,the ER MD did not place Mr. B under a mechanical ventilator, eventhough the patient had apnea and abnormal arterial blood gas results.


Patientsadmitted to the emergency department should have their vital signsmonitored at fifteen minute intervals. In the case of Mr. B, if thiswas carried out, nurse J would have definitely noted the decline inrespiratory distress of Mr. B and the rapid change in hisconsciousness level. Additionally, the hospital should introduce aprogram whereby the nurses will be continually trained at six monthintervals with the aim of improving the care that nurses accord topatients. During the training, it should be ensured that theregistered nurses (RNs) and the MDs are trained on how a propersedation protocol is done. A code team should also be present at theemergency department every time. This will go a long way in solvingthe understaffing issue, as well as relieving patients off the painand anxiety that accompany their primary complaints, increasing thelevels of patient satisfaction. However, this alone will not solvethe staffing issue, and more staffs still need to be deployed to theemergency department. A high workload of the nurse will lead toincreased nursing errors and negligence as seen in the case of Mr. B.At all times, the hospital should ensure that it has at least tworegistered nurses available. The hospital procedures and policiesshould also enforce protocols that relate to conscious sedation.Stricter protocols concerning conscious sedation should beimplemented immediately. After implementation of the protocols, itwill be ensured that procedural guidelines regarding sedation aredone according to these protocols. Stern disciplinary action shouldbe taken against any nurse or MD in the emergency department who doesnot follow these improved protocols appropriately in their sedationprocedures.


Thechange theory that can be applied in implementing the processimprovement plan described above is the change theory as described byKurt Lewin. The theory comprises of three concepts, namely: theunfreezing, the change and the refreezing (Elcock, 2010).


Beforechange can take place, it has to undergo the unfreezing stage.Employees in an organization are usually resistant to change (Elcock,2010). The aim of this unfreezing stage is to create acceptanceawareness. The employees are thus communicated to and encouraged toembrace change and stay motivated.


Thispart represents the actual transition as the organization is in astate of improvement. Here, the employees begin to adopt and learnnew behaviors and thinking models. The employees are constantlyreminded how the change will benefit both the healthcare personneland patients.


Therole of this stage is to harden the change that has already takenplace. It is there to ensure that already transformed employees donot regress back to their old thinking models.

Thischange theory promotes the creation of trusting relationships amongthe members of the staff. This will be crucial in making the currentnursing staff and MD accept, incorporate and work together with theincoming code team and the additional nursing staff that may beintroduced to this emergency department. It will also encourage allthe staff in this department to work and think issues throughtogether with the aim of coming up with common solutions. The changetheory also promotes the acquisition of information on the currentstate of the emergency department in a continuous manner. Thisacquisition of information will enable the hospital management andthe concerned parties to realize that the emergency department isunderstaffed, and that there is a need for an improvement of thehospital’s sedation policy. This will facilitate the implementationof the improvement plan mentioned above. Regular acquisition ofinformation regarding the state of this department, as promoted bythe change theory, will be crucial in ensuring that the events thatled to this root cause analysis do not happen again. When the goalsof the implementation plan are attained, and the management hasconfidence that the sentinel events that led to this root causeanalysis are unlikely to happen again, then refreezing of the newlyintroduced system can occur.

FailureModes and Effect Analysis (FMEA)

FMEAis a tool that uses systematic analyses in the evaluation of anexercise to identify the possible areas in which it may fail and ratethe magnitude of impact of different types and modes of failure. Thesteps that are carried out in the process, the possibilities offailure, the reasons for the failure and the consequences of thesefailures are thoroughly analysed. It is very crucial to carry out anFMEA as a team.

Membersof interdisciplinary team

Themembers of the FMEA team would be a group of nurses from alldisciplines, who work in the emergency department, doctors from alldisciplines in the emergency department, the staffing coordinator,hospital supervisor, pharmacist, the director of nursing in thehospital and the overall medical director. The nurses and doctorsfrom the emergency department will be chosen because they are the onewho have the experience of working in the emergency department of thehospital on a day to day basis, and so can relate well with theproblems that the department was facing before the implementation ofthe improvement plan and can give first-hand information as towhether and how the improvement plan has been effective in solvingthe issues that they were previously facing. The pharmacist will bechosen because s/he is a professional in sedation, and s/he will becrucial in analyzing the sedation protocols that were implemented.The staffing coordinator will be able to provide information as towhether and how the newly introduced staff to the department and thecode team solved the staffing issues that were previouslyexperienced. The hospital supervisor, director of nursing and overallmedical director will be in the team because they are in positions ofadministrative power, and they will be necessary in authorizing anychange or any activities implicating to operations that may benecessary.


Oneof the major causes of failure in the care of Mr. B was the failureof the nurses to follow a proper sedation protocol that relates tothe conscious. The improvements and implementation of this improvedsedation protocol was aimed at educating the nurses in the emergencydepartment of the appropriate sedation protocols. It will thus beevaluated if the nurses were properly enlightened as per the modernand updated sedation protocols. With this regard, the FMEA teamselected will obtain and evaluate all data (internal and external),scope of practice for doctors and nurses and guidelines of clinicalpractice that are defined by the Board of Registered Nursing. Currentpolicies and procedures in other accredited hospitals that relate toconscious sedation will also be obtained. Information regardingconscious sedation that will be obtained from all these sources willbe used to analyse and evaluate the current conscious sedationpolicies and procedures applied in the hospital.

Theteam will also obtain a staff (nurses) to patient ratio analysisbefore the improvement plan is implemented. The staff to patientratio after the proposed improvement plan is implemented will also bedetermined. These ratios will be used in analyzing informationshowing how the staffing supply of the emergency department in thehospital relates to the quantity of patients.


TheFMEA consists of three steps, namely: severity, occurrence and lastlydetection. Severity shows the extent of badness of an outcome.Occurrence deals with determining the likelihood that the outcomewill take place. Detection shows the easiness of visualizing theoutcome. Each member of the FMEA team will assign a number for thepossibility of occurrence, detection and severity. This number isknown as the Risk Priority Number (RPN) and is a value that showsprobability (Gianini, 2015). The Risk Priority Number formula is anumeric assessment of the process, and it is a huge part of the FMEAanalysis. The team will assign every failure mode a number from oneto ten, which will represent a numerical value of how much the team,views the process as deemed to fail. The numerical grading is viewedas a means of quantification of failure, shows the possibility offailure not being detected and the impact of damage that the failuremode may induce to somebody (Latino, 2015).


Theconscious sedation protocol will be evaluated and reviewed by thecommittee within ten days of its implementation. This will have theaim of ensuring that safe practices are implemented. Within theperiod of thirty days, all the nurses will be properly educated andenlightened of the hospital’s conscious sedation protocols. Theemergency department staff will also review updates and reviews ofconscious sedation every ninety days. The staff will also be educatedannually on conscious sedation protocols, mechanisms of action andmodes of administration. With regards to staffing, safe and effectivestaff (nurses) to patient ratios will be introduced and implemented.

Roleof Nurses

Nursesare the first people in the hospital and healthcare setting whoidentify a crisis situation. This sets the tone for the course ofaction to be followed by other hospital personnel. Nurses can alsoencourage fellow junior nurses as well as other staff in thehealthcare team to follow hospital protocol and ensure that safety ofpatient care is achieved and maintained.


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Latino,R. (2015). How is the effectiveness of root cause analysis measuredin healthcare?. JournalOf Healthcare Risk Management, 35(2),21-30. http://dx.doi.org/10.1002/jhrm.21198

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