Patient Safety and Quality in Healthcare NURS402
- Subject Code :
NURS402
Case Study: Patient Safety & Quality
Instructions:
Complete a root cause analysis (RCA) based on the below scenario. A RCA is a commonly used process in the healthcare industry when an error occurs. The RCA is a structured method that follows a series of steps to discover the root cause(s) of an issue. A main focus should be to identify the underlying problem(s) for the error while avoiding focusing on mistakes by individuals.
Scenario:
You are a CNS for a large stand-alone hospital. You have been assigned to the Patient Safety and Quality Committee that addresses all errors and near miss reports. The committee is assigned to complete a RCA report and Action Plan for any incident reports.
On Monday, the committee is assembled due to an event that occurred over the weekend. The report that is received is as follows: The emergency department (ED) triaged a patient on Saturday evening that presented herself with severe depression and thoughts of hurting herself for the past 3 days. While the RN was triaging her, she experienced a seizure. The RN activated the rapid response team for assistance; the patient was stabilized and immediately brought back to a room. The RN completed the triage; however, did not communicate with the receiving RN that the patient was suicidal; hence, no suicidal precautions were implemented for this patient. When the RN went to assess the patient, he noted that the patient had the cardiac monitor wires around her neck, he immediately took action and cut the wires. The RN immediately placed the patient on suicide precaution; all the equipment from the room was removed, and the patient was placed on a 1:1 observation. The charge nurse was informed who then completed the incident report. The incident report was received and the Patient Safety and Quality Committee was summoned.
- Based upon the given scenario complete the Root Cause Analysis Template (see below). Be as thorough as possible. Provide your information in complete sentences.
- Remember that the focus of the RCA process is not to blame anyone individual. Consider this from a systems level perspective. What are some of the interventions that you can consider to help improve this situation. Think about ways that technology may be incorporated to assist.
- Complete the Root Cause Analysis Action Plan Template. Make sure to consider at least four action items that might be considered to reduce the risk of future occurrences.
Root Cause Analysis Template
|
Analysis |
Questions |
Findings |
|
What happened? |
What are the details of the event? (Include a brief description) |
|
|
When did the event occur? (Date, day of week, time) |
||
|
What area/services was involved? |
||
|
Why did it happen? |
What are the steps in the process? (A diagram may be helpful to include) |
|
|
What factors were involved in the situation? |
What steps were involved in or contributed to the event? |
Root Cause Analysis Action Plan Template
|
Risk Reduction Strategies |
Measure(s) of Effectiveness |
Responsible Person(s) |
|
Action item: |
||
|
Action item: |
||
|
Action item: |
||
|
Action item: |
Case Study: Patient Safety & Quality
Grading Criteria
|
CRITERIA |
POINTS POSSIBLE |
POINTS EARNED |
|
1. RCA a. Addresses all five questions within the template with thorough descriptions. b. Findings reflect a thoughtful perspective that examines the issues from a process level. |
45 |
|
|
2. RCA Action Plan a. Proposes four action items that are considerate and reasonable. Action items must address processes. b. Provides an evaluation measure for each of the action items. Measurements must be measurable and realistic. c. Identifies a role that is responsible for each of the action items. The responsible role must be realistic. |
45 |
|
|
3. Scholarly Writing a. Incorporate at least 3 current (2019-2024) scholarly references to support your actions. b. These references are included on a separate, APA-formatted page. |
10 |
|
|
Appropriate use of APA guidelines and free from grammatical and/or spelling errors |
-0.5 per error |
|
|
Total |
100 |
|
