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Root Cause Analysis

RootCause Analysis

Rootcause analysis can be described as a tool that entails of a widerange of problem-solving techniques which are used in identifyingorigin causes of faults. It is a means of finding out causes ofnegative events and detects both active and latent errors. Dynamicerrors are caused by tasks carried out by human activities whilepotential errors are those that occur in the health care deliveryenvironment created by either equipment or organizational flaws.Active and possible errors can also be described as the sharp end andblunt end respectively. During this process, investigations arecarried out and the information collected is used to develop change,and recommendations in the affected area since the elimination ofthese problems improves safety in the healthcare system(AmericanNurses Association,2016).

Bothpatients and caregivers and affected with the different types oferrors. The following are examples of factors that may lead topotential mistakes and how they impacted different person’sinvolved-Management/ organizational flaw- a caregiver, for instance,a nurse detects a problem, but the physician discourages her fromreporting it. Staffing- an overworked caregiver mistakenly given thewrong dosage to a cancer patient leading to hemorrhage.

Patientcharacteristics- the guardian of a young girl misread the dosageinstructions on her drugs causing her severe kidney infections.

Task-related- a resident incorrectly calculated diabetes drugs to astroke-stricken sick person that resulted in a brain clot andhemorrhage. His nurses notify team environment- a surgeon that ascalpel is missing, but he ignores and completes an appendectomy. Thescalpel is later detected inside the patient after some complicationsrequiring a reoperation.

Workenvironment- staff improvising during operations due to lack ofequipment leading to further complications or even death of thepatient in question. Institutional flaw- a patient receivedAmyotrophic Lateral Sclerosis dosage and his health deteriorated muchfaster than expected and this prolonged his hospitalization. Thehospital was under pressure to improve its Amyotrophic LateralSclerosis drugs. Errors can be analyzed using the systems approach.In this method the following steps are crucial:

  • The investigation is started

  • Information is gathered and mapped

  • Service and care delivery problems are identified

  • Analysis is conducted to identify any contributory factors and or root causes

  • Solutions are generated

  • Auditing and learning from the reports

Afterthe investigation is completed, the probability of these problemsoccurring is clearly spelled out in the report findings. Solutions tothese mistakes include eliminating distractions in work areas, andminimizing work rounds. Minimizing job shots and shifts helps inreducing fatigue(PatientSafety – About the Patient Safety division,2016).When a nurse is tired, her/his ability to deliver the best care willbe affected. Fatigue increases risks of errors by impairing one’scommunication skills and moods. According to ANA “.Theramifications of nurse fatigue are serious. Scientific evidence linksshift work and long working hours to many health effects includingcardiovascular disease and cancer. Fatigue can also affect nurse’sability to deliver optimal patient care….” (ANA 2016) Checklistsshould also be used to avoid omission of any important step(s) duringdifferent medical procedures. Paying more attention to devicesemployed in medical facilities to prevent slips is also recommended.Extensive training and supervision will also assist in eliminatinglikelihood mistakes.

Medicalpersonnel are encouraged to create a ‘culture of safety’ and toreport any active errors. According to American Nurses Association’culture of safety’ is defined as (ANA 2016) “core values andbehaviors resulting from a collective and sustained commitment byorganizational leadership, managers and healthcare workers toemphasize safety over competing goals…”

Revisinghow care systems and protocols work will also aid in the reduction ofpotential errors. Errors are human or machine caused, and can lead tosevere consequences as seen. If possible, caregivers should strive toavoid the mistakes to improve safety in their work environment(PressureUlcer Prevention Challenge,2016).


  1. Nursing Sensitive Indicators

Nursing-sensitive indicators are the indicators that outline results andstructures of nursing care. These indicators are classified intostructural, process and outcome indicators. Process indicationsinclude the clinical judgments of the nurses and steps taken as aresult of the analysis and patient assessment methods. Structuralindicators include the number of staff present, the level ofeducation and skills of the nursing staff. Outcome indicators includepatient falls, pressure ulcers, the length of hospitalization, andreadmission rates among others.


Inthe above- given scenario, Mr. J a 72- year- old is hospitalized. Onvisiting him, his daughter notices some strange things. She findsthat her father is restrained. It is because of the previous fall hehad. Her father also has mild dementia, a disorder that affects thebrain, and is characterized by changes in personality and memorylapses. Which can result in behaviors that could lead to further harmto the patient’s heath? For example, Mr. J could forget that he isin a hospital bed with a fractured hip, get up and fall. The fallwill harm Mr. J further and in an extreme case cause furthercomplications that may lead to death. The restraining by the nursesis justified.

Restraintprevalence is one of the outcomes used in Nursing SensitiveIndicators (NSI’s). Controls are used in many different medicalfacilities. Constraints can be utilized for the following reasons: to put a patient in the right position on a stretcher or in bed,preventing violent and confused patients from causing harm to him andthose around him, when administering some drugs restraints arerequired. Understanding this factor of control assists the nurses inkeeping Mr. J safe from harm.


Mr.J’s daughter notices a red depressed area over her father’ssacrum that was similar to sunburn. Medically, pressure ulcers aredefined as the ulcerated part of the body particularly the skin thatresults from irritation and application of pressure on the part ofthe body. If not treated, pressure ulcers lead to damage of the boneand skin this damage can be permanent. Pressure ulcers can affectone’s bottom, elbows, heels, hips, the sacrum like in Mr. J’scase and the back of the head and shoulders.

Mr.Jis restrained and left lying on his back. That means thatpressure is exerted on his lower back, when asked the nursingassistant told the daughter not to have any worries the sore will goaway, yet she isn’t sure when the patient will be able to get up onhis own. If the certified nurse assistant were well informed onpressure ulcers, she would have acted differently.

Toavoid this scenario, the certified nurse would have taken measures tomaking sure that the patient is turned to different positionsregularly. It relieves pressure exerted on one part of the body. Ahealthy diet also assists in reducing pressure ulcers. The healthcareprovider should have also been conducting regular checks on Mr. J,the wound which as described, resembles severe sunburn. It impliesthat it has been present for a while and no therapeutic measures havebeen taken.

Thenurse should also have used pressure relieving devices as she knewthat Mr. J is restrained, and chances of him suffering from pressureulcers are very high, these devices include special mattresses andcushions put on the back of the patients to prevent such events.

Ondetecting that the patient suffers from pressure ulcers the nurseshould have taken corrective measures such as changing the patient’sposition when she brought him back to bed, instead, she had him lieon his back, the same position she found him. Replacing the patient’smattress with a pressure relieving mattress, the nurse should havedressed the wound and offer antibiotics to prevent infection of thewound. Instead, she told the daughter that the injury would go awayas soon as the patient gets up.


Patientsatisfaction plays a significant role in the progress of a healthcareinstitution. If patients are not satisfied, then that means that thecaregivers are not performing to their optimal. In the scenarioabove, the patient’s diet order wasn’t what was delivered. Oncomplaining, the physician pointed out that this was not the firsttime the mistake was being made. In fact, patients who are of theJewish origin prefer to seek to receive medical attention from afacility 20 miles away, because the hospital staff doesn’t taketheir dietary requests seriously (NursingQuality Indicators,2016).

Ifthe caregivers were aware of the nursing-sensitive indicators, thenthey would take each patient’s request seriously. Retainingpatients is one of the signs of patient satisfaction and yet in theabove scenario we see patients opting to seek treatment 20 milesaway. When patients are satisfied with the healthcare servicesprovided, then this aids in the healing process.

Failureto Rescue

Failureto rescue can be described as institutions fail to recognize and takeaction to early signal that indicates deteriorating of a patient’shealth. It is one of the indicators of quality of the healthcareservices provided by an institution Failure to rescue contributes tomortality.

Inthe above scenario, the nurse is made aware of the pressure ulcersthat Mr. J is developing but does nothing about it. Mr. J is a 72-year -old man, diagnosed with mild dementia, has a fractured hip andis now developing pressure ulcers but this doesn’t bother thenurse. Her response is rather disturbing, and it implies that thewound is no big deal, yet it is seen to have severe effects on thebones and skin if left untreated. If the nurse were aware of theconcept failure to rescue and its consequences which includemortality and increased morbidity, then she would have taken thenecessary steps that will eventually suppress the sore that Mr. J hasdeveloped.

  • How data on specific nurse-sensitive indicators could advance patient care.

Asystem should be put in place to record the number of incidences bothpositive and negative that have resulted due to impacts on nurse-sensitive indicators. The data collected should be analyzed, and theresults shared among caregivers to reduce the number of preventablemedical cases.

Onpressure ulcers, for example, a database should be put in place. Itshould entail the number of patients that have acquired patientulcers after being admitted to the hospital and a percentage ratederived. Preventive measures used on patients, as well as curativemeasures that were used on affected patients, should be outlined, toequip the healthcare providers with workable solutions. The number offatalities should also be indicated.

Healthcareproviders should have their individual targets according to their ownfacilities. In facilities where there are many cases of pressureulcers arise, for example, they should take the necessary steps inreducing the numbers with the aim of eliminating such cases entirely.

  • Resolving The Ethical Issue

Variousethical issues are present in the above scenario. The ethical issuesinclude dishonesty this is seen where a nurse notified thesupervisor of the dietary confusion that had occurred and the nursewas told to keep it quiet. It is also seen when the daughter is notinformed of the incident, and while the daughter went to confirm theevent she got an annoying response. Dishonesty has affected both theprinciples and professional behavior of the staff.

Asa nurse- shifting supervisor I would first take disciplinary actionagainst hospital employees who handle patients’ dietary requests.It is because many Jewish patients have raise complaints, and haveeven sought to seek medical care from other facilities (RootCause Analysis | AHRQ Patient Safety Network,2016).To reduce the dishonesty, I would establish a whistle- blowingprocedure that ensures that any activity that is unethical isreported in due time and action is taken. Consequences for eachundesirable action will be clearly spelled out.


Causeanalysis is seen to be a problem -solving technique that identifiesproblematic areas and errors if present is enabling the institutionto make corrections where necessary. Nursing Sensitive Indicators isa means of deterring the quality of healthcare provided by anorganization. When outcomes of the nursing sensitive information areconsidered then the medical facility will flourish, deaths and othercomplications will be avoided and patients satisfied with the serviceprovided.


AmericanNurses Association.(2016). Nursingworld.org.Retrieved 17 November 2016, from http://www.nursingworld.org

PatientSafety – About the Patient Safety division.(2016). Nrls.npsa.nhs.uk.Retrieved 17 November 2016, fromhttp://www.nrls.npsa.nhs.uk/about-us/

PressureUlcer Prevention Challenge.(2016). Nursingworld.org.Retrieved 17 November 2016, fromhttp://www.nursingworld.org/HomepageCategory/NursingInsider/Archive-1/2013-NI/Feb-2013-NI/Pressure-Ulcer-Prevention-Challenge.html

RootCause Analysis | AHRQ Patient Safety Network.(2016). Psnet.ahrq.gov.Retrieved 17 November 2016, fromhttps://psnet.ahrq.gov/primers/primer/10/root-cause-analysis- root ofan error

NursingQuality Indicators(2016). TheSentinel Watch.Retrieved 17 November 2016, fromhttp://www.americansentinel.edu/blog/2011/11/02/what-are-nursing-sensitive-quality-indicators-anyway/