Case Studies

Unit 5: Chapter 22: Quality Patient Care Case Studies

Case Study 1:
A patient at Alvin Community Hospital is sent to the 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 identification labels.   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 identification labels 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)?
The hospital’s risk management department is responsible for initiating a root cause analysis.
2. In regards to conducting a root cause analysis:

A. Who would you contact to conduct a root cause analysis?
To conduct the root cause analysis you would contact the hospital’s risk management department.

B. What should be included to determine the cause of the problem?
These include problems within the system, work-design problems, or human and environmental factors.

C. Who should be included?
The patient’s nurse, patient’s doctors, unit secretary, charge nurse, patient care assistant/techs, and any staff who had contact with the patient in the cardiology unit.

D. What’s the purpose of conducting a root cause analysis?
The purpose of the root cause analysis is to identify all factors that lead to the error and find ways to avoid repeating the errors.

3. The hospital has a non-punitive policy for mistakes and errors.   How does this affect the RCA if the cause of the problem is identified as a mistake by the unit secretary?
It has not effect on root...