Root Cause Analysis-Mr Jones Case Study

Root Cause Analysis-Mr Jones Case Study

According to Rodziewicz et al. (2022), medical errors are a major and critical public health issue of concern in the United States. The Agency for Healthcare Research and Quality (n.d.) notes that these medical errors can happen at any point within the healthcare system and care process. They have multiple causes with significant unwanted outcomes, including patient harm, death as well as career consequences. This paper analyses the case of a patient, Mr John Jones, defines the issue and identifies its root causes. It also identifies the interdisciplinary review team, develops an evidence-based intervention for the incident, and recommends safety measures to prevent such incidents from reoccurring.

The Basic Issue and Root Cause of the Issue

Mr Jones suffered an ABO incompatibility reaction after the blood treatment was administered. From the root cause analysis (RCA), there are various factors that contributed to the occurrence of Mr. Jones’ event. These include errors in the registration of the patient, failure to confirm the patient’s full details, assigning the student nurse roles above his qualification without supervision, distraction, and miscommunication. Analyzing the chronology of events shows that the registration error by the student nurse was the root cause of the issue. Errors in the patient registration at any point in a blood transfusion chain obscure the patient’s historical information leading to misidentification, which further risks ABO discrepancies and associated outcomes (Cohen et al., 2019).

Members of the Interdisciplinary Review Team

The members of the interdisciplinary review team of the incident are nurses, a related physician, a nurse informaticist, a laboratory technologist, a pharmacist, the patient, two family members, and the student nurse technician. To begin with, the nurses will provide the required bedside care and checks. The physicians will provide advanced care to the patient, review treatment plans, organize the care team, and prescribe medications and other treatments. Further, the laboratory technologist will ensure objective testing and diagnoses. Next, the nurse informaticist will provide support with the management of electronic patient information, support sharing and readiness of the information within the system, and review the stored electronic information to ensure its accuracy. The pharmacists will confirm all medications before they are administered to the patient. Finally, the patient and the family members are team members as they are required to consent to any actions taken during the patient’s treatment process, while the student nurse will provide support to the team as they learn.

Reliable and Evidence-Based Interventions to Prevent a Similar Incident from Occurring

Errors related to blood transfusion can be prevented by making significant changes in the processes of transfusion. These include ensuring that the nurses administering the ABO treatment first confirm the blood type from the system and cross-check with another care provider involved in caring for the patient. Another reliable intervention is to make changes in the related human processes through the use of technology throughout the ABO transfusion process. This means eliminating all instances where human errors can occur, including patient registration, reading and recording patient IDs manually and printing out orders. Notably, the use of biometric identifiers has been noted to improve patient registration, reduce instances of obfuscation of patient historical information, and reduce patient misidentification, with an impact on the safety of transfusion (Cohen et al., 2019).

Proposed Safety Measures to Prevent This Incident from Reoccurring

The proposed safety measures to prevent the reoccurrence of the incident in Mr Jones’ case include ensuring that the team is aware of the root causes of the initial incident and learning from it. This means identification of the errors leading to the incident as caregiving challenges that the team should overcome collectively. Another measure is to avoid punishing the parties involved but provide them with support to learn from their mistakes. Additionally, the team needs to be trained on interdisciplinary approaches and consistency in identifying risk factors for medical errors within an interdisciplinary team care setting.

Conclusion

In conclusion, the case of Mr John Jones shows how errors at one point in the treatment process can be propagated to lead to a life-threatening incident. ABO incompatibility is an issue of concern in blood transfusion treatment that is related to errors in patient registration. Such events related to registration errors and patient misidentification can be resolved by adopting patient identification technologies such as biometric identifiers and consistently identifying and learning from previous mistakes.

References

Agency for Healthcare Research and Quality. (n.d.). Medical Errors. Retrieved March 3, 2023, from https://www.ahrq.gov/topics/medical-errors.html

Cohen, R., Ning, S., Yan, M. T. S., & Callum, J. (2019). Transfusion Safety: The Nature and Outcomes of Errors in Patient Registration. Transfusion Medicine Reviews, 33(2), 78–83. https://doi.org/10.1016/J.TMRV.2018.11.004

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2022). Medical Error Reduction and Prevention. StatPearls Publishing.

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In this written assignment, you will explore a patient incident using root cause analysis using the required template located in this week’s module.

Root Cause Analysis-Mr Jones Case Study

Step 1 Read the scenario.

Download and read: Root Cause Analysis Scenario Handout Download Root Cause Analysis Scenario Handout.
Step 2 Complete the chart.

You have been charged with leading the interprofessional team that will investigate Mr Jones’s issue. Your analysis should focus on systems and processes, as well as individual performance.

Download and complete the Root Cause Analysis Chart.
Step 3 Develop a plan of action.

Based on your investigation, develop a minimum two-page plan of action, not counting the title or reference page, detailing the recommendations your team makes. Your paper will need a title page, introduction, body, conclusion, and reference page.

Use distinct paragraph headers to answer/discuss the following in the body of your paper:

Identify the basic issue and summarize the root cause of the issue.
Who would you like to see as part of the interdisciplinary review team? Why?
Use research to develop several reliable and evidence-based interventions to prevent a similar incident from occurring.
What safety measures did you propose to prevent this from reoccurring?
Cite your research in-text and provide references. Use 7th edition APA to formulate your professional paper. A sample paper has been provided for you to use as a template for this assignment in this week’s module.

Attach the completed Root Cause Analysis Chart to the end of your paper as an appendix or attach it separately with your assignment.
Step 4 Save and submit your assignment.

Click on Assignment 9.1 to submit the assignment.

See rubric for grading details

*Important: Use the Sample Paper as a template to format your assignment to prevent unnecessary point deductions.

Rubric
Paper Grading Rubric
Paper Grading Rubric
Criteria Rating Pts
This criterion is linked to a Learning Outcome Introduction
5 to >4.0 pts
Excellent
• The main topic is stated and gives the reader an idea of what to expect in the paper. • Stimulates reader to desire to read further. • Not to exceed 1/2 of a page but at least 3 complete sentences.
4 to >2.0 pts
Satisfactory
• The main topic is stated but gives the reader little idea of what to expect in the paper • Short, choppy, fragmented paragraphs. • Not specific enough to let the reader know what to expect.
2 to >0 pts
Needs Improvement
• Vague, no main topic introduced; does not give the reader an idea of what to expect in the paper. • Begins the content of the paper without introducing the topic.
5 pts
This criterion is linked to a Learning Outcome Content
20 to >14.0 pts
Excellent
• Writing is focused on the main topic. • Meets all criteria given for the paper. • Integrates professional opinion with research to present a thorough evaluation. • Presents the subject accurately and completely while synthesizing research. • Clear paragraph headers to organize the paper.
14 to >8.0 pts
Satisfactory
• Writing is relevant to the main topic. • Meets most criteria given for the paper. • Minimally integrates professional opinion with research. • Mostly accurate and complete, unclear. • Paragraph headers do not clearly organize paper content.
8 to >0 pts
Needs Improvement
• Writing does not address the main topic. • Meets some of the criteria given. • Is vague and incomplete – components are missing, inaccurate, or unclear. • Missing paragraph headers. • Does not integrate professional opinion with research into the paper.
20 pts
This criterion is linked to a Learning Outcome Conclusion
5 to >4.0 pts
Excellent
• The concluding paragraph is clear; it ties the paper together by summarizing the main topics. • No new information is presented.
4 to >2.0 pts
Satisfactory
• The concluding paragraph is somewhat clear; it summarizes the main topics. • Some new information was presented.
2 to >0 pts
Needs Improvement
• Conclusion unclear and does not summarize main topics. • Mostly new information presented.
5 pts
This criterion is linked to a Learning Outcome Format
10 to >8.0 pts
Excellent
• Paper is coherently organized. • No spelling or grammatical errors • Writing is clear and concise. • Well-developed paragraphs. • Paper has 1-inch margins, Times New Roman 12-point font. • Title page, body, & reference page follows 7th ed. student paper format.
8 to >4.0 pts
Satisfactory
• Paper is generally well organized • Minor spelling or grammatical errors • Writing is mostly clear but may lack conciseness. • Short, choppy, fragmented paragraphs • Paper margins are not consistent. • Title page, body, & reference page mostly follows 7th ed. format.
4 to >0 pts
Needs Improvement
• Paper is poorly organized and difficult to read – does not flow logically. • Many spelling and/or grammatical errors. • Writing lacks clarity and conciseness. • Incomplete paragraph format. • Title page, body, & reference page does not follow 7th ed. student paper format.
10 pts
This criterion is linked to a Learning Outcome APA
** Plagiarism = 0 points in all areas
10 to >8.0 pts
Excellent
• Very minor to no APA errors for in-text citations and reference format. • Follows 7th ed. APA format for student papers. • Research is reliable and presented in writing using in-text citations with each source listed on the reference page.
8 to >4.0 pts
Satisfactory
• Few APA errors for in-text citations and reference format. • Primary research sources are unreliable. • Missing some in-text citations showing research. • Inconsistent APA format.
4 to >0 pts
Needs Improvement
• Many APA errors; poor set-up & formatting. • In-text citations do not match reference page sources. • No research proven in writing using in-text citations. • References lack APA format; weblinks only
10 pts
Total Points: 50
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