Root Cause Analysis
It is important to evaluate all aspects of the sentinel event as well as the events that led up to Mr. Bs death. The questions that follow are pertinent because they set up a scenario with valid questions that need to be answered. The goal is to identify errors and prevent reoccurrences incident in the future. In the case study, it appears that a lack of protocols as well as a lack of communication amongst staff members may have been contributing factors which led to death of a patient in the emergency department.
In carrying out a root cause analysis, it is helpful to re-create the event with the staff members integrated in the event. Members of
In order to evaluate interventions set forth to improve care documentation of what could go wrong , why would the failure happen and thirdly would be the consequences of such failure. Staffing was a factor as there was only one RN staffed in a critical setting. Chart audits would be instituted to identify documentation is complete. Shift start will include monitor checks to assess that monitor alarms are functioning appropriate. FMEA is a great tool to be used in risk analysis and quality control, its use proactively evaluates health care processes. The FMEA steps are:
Step One: Select a process to evaluate with FMEA.
Step Two: Recruit the Multidisciplinary team. Team is anyone who comes in contact with patient.
Step Three: Team to meet to discuss the steps in the process.
Presteps for preparing for the FMEA are evaluating subgroups, identify a potential issue and identify members in the multidisciplinary group that will institute the process.
As noted in (Wikipedia, n.d.) Severity classification is assigned for each failure mode of each unique item and entered on the FMECA matrix, based upon system level consequences. A small set of classifications, usually having 3 to 10 severity levels, is used.
Occurrence is rated on scale of 1 through 10 where one is