Case Studies

Quality Patient Care
Case Study 1
A patient at your hospital is sent to cardiology for a routine test. The patient returns without incident, and you document the time and condition of the patient upon return to the room. The next day you are summoned to the unit manager's office, along with the charge nurse and unit secretary. The manager describes how the patient's chart had a different patient's face sheet and blue plate. The manager demands an explanation for the incident since controls are in place that should eliminate problems such as this (all patient charts going off the floor for procedures must be checked by the nurse and unit secretary for proper blue plate and face sheet). This procedure is in place due to similar incidents on other floors.
1. Who is responsible for initiating a root cause analysis (RCA)?
Risk management department
2. How would you conduct a root cause analysis to determine the cause of the problem? Who would you include? What is the purpose for conducting the RCA?
1) Data Collection
2) Casual factor charting: provides structure for investigators to organize/analyze the information gathered during the investigation and ID gaps and deficiencies in knowledge as investigation progresses. The casual factor chart is simply a sequence diagram with details of events leading up to the occurrence and the conditions surrounding these events.
3) Root cause identification: after all casual factors have been identified, you begin root cause identification.   When you identify the root cause you help investigators determine the reasons the event occurred.
4) Recommendation generation and implementation: to prevent the reoccurrence of the event(s).
The people to be included are: The patient’s nurse, patient’s doctor, unit secretary, charge nurse, patient care associates and any staff who had contact with the patient while in the cardiology unit.
The purpose for conducting the RCA is to identify all the factors that led up...