1. A patient with atrial fibrillation (heart arrhythmia), is placed on warfarin, a blood thinner, by his cardiologist. He 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...
PS 201: ROOT CAUSE ANALYSES AND
ACTIONS
1. A patient with atrial fibrillation (heart arrhythmia), is placed on warfarin,
a blood thinner, by his cardiologist. He 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 RCA2. 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 abnormal
results and associated updates to their plan of care. Which of the
following is the best recommended action statement?
a) Patients need to have their INRs checked more frequently.
b) With a goal of 99% of patients receiving calls within 2 days of their
results: Have the phlebotomy lab automatically generate a list of all
patients who h - answer-b) With a goal of 99% of patients receiving calls
within 2 days of their results: Have the phlebotomy lab automatically
generate a list of 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 the results.
4 steps RCA2 team should take in their investigation - answer-1. organize
its initial understanding of what happened: flow diagram
2. identify gaps in knowledge: generate questions and a list of patients,
staff to interview
3. collect info from environment and written documents (walking through
or observing areas involved in the event, reviewing medical records,
examining equipment, reviewing equipment manuals, and researching
recommended practices)
4. conduct interviews
7 categories of contributory factors that influence clinical practice (Charles
Vincent) - answer-Institutional context
Organizational and management factors
Work environment
Team factors
Individual staff members
Task factors
Patient characteristics
a causal statement - answer-links the causes the team identifies to the
effects and then back to the main event that prompted the RCA2 in the
first place
A causal statement has three parts: - answer-1. The cause: "This
happened..."
2. The effect: "...which led to something else happening..."
,3. The event: "...which caused this undesirable outcome."
a cause and effect diagram or 'fishbone' diagram - answer-tool that helps
teams identify contributory factors and visually group them
a systems approach to error asks: - answer-"What circumstances led a
reasonable person to make reasonable decisions that resulted in an
undesirable outcome?"
This mindset is how to actually make systems safer.
A template can help ensure all components are in place. This example
prompts the team to associate each causal factor with an ______, each
______ with a set of _______, and each set of _______ with a ______. - answer-
associate each causal factor with an action, each action with a set of
measures, and each set of measures with a plan.
action hierarchy: INTERMEDIATE - answer-1. Redundancy.
- Example: Use two RNs to independently calculate high-risk medication
dosages.
2. Increase staffing/decrease workload
- Example: Make float staff available to assist when workloads peak during
the day.
3. Software enhancements, modifications.
- Example: Use computer alerts for drug-drug interactions.
4. Eliminate/reduce distractions
- Example: Provide quiet rooms for programming PCA pumps; remove
distractions for nurses when programming medication pumps.
5. Education using simulation-based training, with periodic refresher
sessions and observations
- Example: Conduct patient handoffs in a simulation lab/environment,
followed by critiques and debriefing.
6. Checklist/cognitive aids
- Example: Use pre-induction and pre-incision checklists in operating
rooms. Use a checklist when reprocessing flexible fiber optic endoscopes.
7. Eliminate look- and sound-alikes
- Example: Do not store look-alikes next to one another in the unit
medication room.
8. Standardized communication tools
- Example: Use read-back for all critical lab values. Use read-back or
repeat-back for all verbal medication orders. Use a standardized patient
hand-off format.
9. Enhanced documentation, communication
- Example: Highlight medication name and dose on IV bags.
action hierarchy: STRONGER - answer-Architectural/physical plant changes
- Example: Replace revolving doors at the main patient entrance into the
building with powered sliding or swinging doors to reduce patient falls.
New devices with usability testing
, - Example: Perform tests of outpatient blood glucose meters and test
strips and select the most appropriate for the patient population being
served.
Engineering control (forcing function)
- Example: Eliminate the use of universal adaptors and peripheral devices
for medical equipment and use tubing/fittings that can only be connected
the correct way (e.g., IV tubing and connectors that cannot physically be
connected to sequential compression devices).
Simplify processes
- Example: Remove unnecessary steps in a process, such as unnecessary
clicks to complete a task in the EHR.
Standardize on equipment or process
- Example: Standardize on the make and model of medication pumps used
throughout the institution. Use bar coding for medication administration.
Tangible involvement by leadership
- Example: Participate in unit patient safety evaluations and interact with
staff; support the RCA2 process; purchase needed equipment; ensure
staffing and workload are balanced.
action hierarchy: WEAKER - answer-1. Double checks
- Example: One person calculates dosage, another person reviews their
calculation.
2. Warnings
- Example: Add audible alarms or caution labels.
3. New procedure/memorandum/policy
- Example: Remember to check IV sites every 2 hours.
4. Training
- Example: Demonstrate correct usage of hard-to-use medical equipment.
after 45 days - answer-1. implementation
2. measurement
3. feedback
an RCA2 needs to be what 3 things? - answer-complete, credible, and
actionable
An RCA2 team is launching an investigation of a surgical error. If they
complete an effective review, which of the following is an example of a
root cause they might identify?
a) The surgeon did not listen to the nurse.
b) The patient was male.
c) The hierarchy in the operating room had a negative effect upon
communication.
d) All of the above - answer-c) The hierarchy in the operating room had a
negative effect upon communication.
as you finalize your recommendations: - answer-- staff/patients/families
may provide insight into whether ideas will reduce risk of future harm
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller TOPDOCTOR. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $11.49. You're not tied to anything after your purchase.
