PS 201: Root Cause And Systems Analysis

Root cause analyses can be useful in health care because: (A) They help to assign blame. (B) They help to identify system failures that can be corrected. (C) They are often quick and simple to perform.

Use the following scenario to answer questions 2 and 3: Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site surgery. His left ankle was operated upon rather than his right ankle. The surgical staff that operated on Mr. Reynolds is embarking on a root cause analysis (RCA) of the incident. If they complete a high-quality RCA, which of the following is an example of the kind of root cause they might identify? (A) The nurse did not listen to the patient. (B) The patient was male. (C) The hierarchy in the operating room had a negative effect upon communication. (D) In this particular case, there was nothing that anyone on the surgical team could have done to prevent an error such as this one.

The team conducting the RCA of the wrong-site surgery realizes that one contributing factor was the pressure on surgical teams to start and end surgeries on time (so as not to disrupt later scheduled procedures). Which of Vincent's seven categories of factors influencing clinical practice does this best illustrate? (A) Patient characteristics (B) Team factors (C) Individual team member (D) Organizational and management factors

Which of the following scenarios would call for a root cause analysis? (A) An occupational therapist quits after only three days on the job. (B) A physician is convinced that there is a better way to deliver pain medications on her unit. (C) A social worker catches a patient who is falling out of bed. (D) An administrator needs to develop a balanced budget.

Which is an important approach when conducting an RCA? (A) Use categories to organize events that led to errors. (B) Focus on a single process in order to consider it in depth. (C) Consider the costs involved in addressing the problems found during the process. (D) Avoid focusing on patterns.

Quinn is a three-year-old boy with a congenital heart malformation. While recovering in the pediatric intensive care unit after surgical correction, he is accidentally given a tenfold dose of heparin. Although he suffers no permanent injuries, the leadership of the hospital rightly decides to conduct a root cause analysis. As they assemble the team, it is crucial that they do the following: (A) Include Quinn's parents. (B) Put together a team of mostly nurses and physicians. (C) Create a team of members who fulfill several roles. (D) Include the health care providers involved in Quinn's care.

What else should the leadership do as they plan for the RCA? (A) Wait to conduct the RCA for a period of time, in order to let the emotions surrounding the incident subside. (B) Make sure that the team conducting the RCA is clear about what they can and cannot review from the records. (C) Make sure the team has time and resources to conduct the RCA, including access to advisors when necessary. (D) Make sure there is at least one member of the senior leadership on the team.

The team conducting Quinn's RCA begins work. What should their first step be? (A) Review the medical literature. (B) Review Quinn's medical records and interview providers. (C) Develop causal statements using Charles Vincent's framework. (D) Review anonymous opinions from providers as to the reasons for this incident, and then construct a list of the most common.

Why should a RCA be conducted by a team rather than by an individual? (A) Understanding what led to an error requires diverse perspectives. (B) A team helps the RCA move more quickly. (C) Individuals usually are not equipped to complete the intense RCA process on their own. (D) Teams are better able to stand up to the conflict that usually comes about when the results of the RCA are made public.

The heart of the RCA process is: (A) Doing a complete and thorough reconstruction of what happened before the event. (B) Defining what should have happened for the patient. (C) Identifying what caused the event. (D) Creating a fishbone diagram.

Use the following scenario to answer questions 6 and 7: Prathibha, a 29-year-old woman, is recovering from same-day knee surgery. While in the post-anesthesia care unit (PACU), she unexpectedly goes into acute respiratory failure and requires intubation. Because she is a young, healthy woman with no medical problems and this was a very unexpected outcome, the charge nurse convenes a team to conduct a root cause analysis. As the RCA for this case begins, the team struggles with identification of the root causes of the outcome. They consider the patient's characteristics as well as the work environment. According to Charles Vincent, what other areas should they consider? (A) Team factors, institutional context, and organizational factors (B) Budget, human nature, and organizational factors (C) Team factors, human nature, and PDSA cycles (D) Psychology, PDSA cycles, and management factors

Which of the following is an example of the type of causal statement that this team might expect to develop? (A) Prathibha hid her diagnosis of asthma, so the team was not aware of her respiratory risks. (B) The nurse responsible for Prathibha was unqualified to monitor complex medical patients. (C) Respiratory compromise can occur in patients with underlying conditions post-operatively. It is unlikely that this outcome could have been prevented. (D) The patient was unattended for 30 minutes because the nurse was busy caring for other patients, and this contributed to the outcome.

Peter, a patient with atrial fibrillation (heart arrhythmia), is placed on warfarin, a blood thinner, by his cardiologist. Peter goes to clinic weekly to have his INR, a measure of how thin his blood is, checked. One week he does not get a call after his bloodwork, and the week after he is admitted to the hospital with a bleeding ulcer. His INR that night is 6, indicating his blood is dangerously thin. A team conducts an RCA. One root cause the team identifies is that the cardiology clinic does not have a specific method to make sure they reach all patients with INRs and communicate their results by the end of the week. Which of the following is the best recommended action statement? (A) The nurse in charge of calling patients with their results should be replaced. (B) Have the phlebotomy lab automatically generate a list of patients all patients who had INRs drawn that day and email them to the nurse, with space to note if the nurse has reached the patient with their results, so that 99% of patients receive calls within two days of their results. (C) Patients need to have their INRs checked more frequently. (D) Patients awaiting lab results should be given access to MyChart, a part of the electronic health record that allows them to access their lab results themselves.

The RCA team working on Peter's case develops several recommended actions. Which of the following is likely to have the strongest impact? (A) Assign more staff to the job of calling patients with their INR results. (B) Post signs reminding the staff to call patients with their INR results. (C) Work with the phlebotomy lab to automatically generate the names of all patients who had INRs drawn that day and send them in an email to the nurse responsible for patient follow-up. (D) Create a policy that specifies that patients with INRs must be called with their results within one week.

The RCA team prepares and shares a summary of their work. What should it contain? (A) A clear description of what happened, root causes, and recommendations for prevention. Team members and methods should be included. (B) A clear description of what happened, root causes, and recommendations for prevention. Estimated costs for implementation should be included. (C) A general description of what happened, root causes, and recommendations for prevention. Team members and methods should be included. (D) A general description of what happened, root causes, and recommendations for prevention. Estimated costs for implementation should be included.

With whom should the team share the report? (A) All providers in the hospital and the public relations office (B) The public relations office (C) Practice leadership and the hospital leadership (D) Hospital leadership and the public relations office

What are some of the limitations of RCAs? (A) They are often conducted by those unfamiliar with the local context of the error and do not always produce actionable recommendations. (B) People participating in the RCA may not be familiar with how to conduct them, and the costs of implementing the actions may be too high. (C) They are often conducted by those unfamiliar with the local context of the error, and the costs of implementing the actions may be too high. (D) People participating in the RCA may not be familiar with how to conduct them, and they do not always produce actionable recommendations.

LaTonya, a young woman with diabetes, dies after being admitted for a kidney infection. What might an RCA NOT be able to uncover? (A) The medical resident caring for her did not know the appropriate antibiotics for this type of infection. (B) There are 23 steps between ordering an antibiotic and administering it on the unit. (C) The new electronic medical system does not have a mechanism to flag "stat" antibiotics for pharmacy. (D) Fatigue among residents is contributing to unsafe care.