Now that we understand the problem, the reason for alarm, and the need to effect change, let’s discuss causation. A problem will have a major (root) cause with the potential for multiple minor causes. The need exists then for organizations to establish systems and processes that prevent or positively decrease the opportunity for medial errors to occur.

Improving and implementing corrections to systems is imperative in today’s healthcare industry.  When errors occur, a process must be in place to analyze and initiate corrective actions.  The recommended process is the performance of a root cause analysis.  As was previously mentioned, JCAHO requires all healthcare organizations under JCAHO accreditation to perform root cause analysis with any sentinel event.

After an adverse event, sentinel event, or “near miss” occurs, there must be a root cause analysis performed to prevent reoccurrence of the same problem.  Those healthcare professionals witnessing and involved in the event will meet with a previously identified group of specific individuals best qualified to assess, analyze, review and create system corrective actions. Three to four meetings may be needed to allow resolution for problem solving. A non-biased team member not personally involved in the incident should be appointed to record minutes for future reference.  The team will review the occurrence and brainstorm for the causative factor (s). The process of recording minutes to have all discussion readily available for review during brainstorming sessions will help with the RCA process. A corrective plan of action addressing system redesign is then formulated and implemented. The work is not finished, though.  A plan to monitor the effectiveness of the redesigned system must be established.  Training and education will follow, to allow implementation of the system changes.  The importance of monitoring to determine the effectiveness of the system changes is crucial to the corrective process.  If there is no method to assess the results of the implemented corrective action plan, then the effectiveness of the plan cannot be assessed, nor can the benefits of the changes be determined.  See appendix for JCAHO’s outline for a framework for the performance of a root cause analysis.

Patient has a diagnosis of chronic obstructive pulmonary disease (COPD).  The patient is unable to maintain viable oxygen saturation levels on room air.  Chart history indicates patient was on home oxygen supplement.  The therapist takes a portable oxygen container to the patient’s room and transfers the O2 connection tubing from the wall line to the portable tank.  Next the patient performs gait training with the therapist for a distance of 140’ using a rolling walker and requiring only SBA.  The patient becomes unstable with increasing shortness of breath.  A wheelchair is accessed.  Vital signs are immediately taken. Nursing is called and arrives.  Heart rate (HR) is 145, blood pressure (BP) is 150/80, oxygen saturation is 79% and dropping.  The patient is returned quickly to his room via a 3-man transfer into bed.  Oxygen supply is transferred from the portable tank to the wall unit. The patient’s oxygen saturation level quickly rises and within 6 minutes, the patient is alert, oriented, but still with moderate SOB.  What has occurred? 

            An immediate presumption could be that the patient is experiencing a medical emergency.  That is true.  An oxygen deficit is occurring that is placing the patient into respiratory distress.  Plans for transporting the patient to a higher level of care might already be in process.  Emergency measures would be considered.  

Further investigation revealed the therapist picked up a portable oxygen tank that was just used by 4 different patients during the morning therapy treatments.  The therapist correctly set and turned on the portable oxygen unit.  The therapist did not assess the level of oxygen stored within the tank.  The tank was empty.

 Think about the following questions:

1.                  Does this episode represent an adverse event?

2.                  Would this be classified as a medical error?

3.                  Should the therapist be reprimanded?

4.                  Could this episode occur repeatedly with other therapists?

5.                  Would the performance of a RCA be appropriate?

6.                  What corrective action should occur?

7.                  State one RCA result that could prevent future similar episodes.

8.                  Should this be classified as a system failure or an individual failure?

 How many times will the same problem and adverse event to patients occur before a system is implemented that will prevent future occurrences?  A result of the performance of a root cause analysis could reveal the need for equipment that alarms when oxygen tanks are empty. This would greatly reduce the opportunity for an adverse event due to the mistake (medical error) of a caregiver connecting an empty oxygen tank to a patient.

Next Page