Root Cause Analysis: Root Cause Analysis or RCA is a method employed in nursing to scrutinize adverse events. It helps healthcare professionals likenurses in identifying factors which “underlie variation in performance” (Anderson et al. , 2010, p. 8). Events where RCA is worthy of being used are defined in research as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof” (The Joint Commission, cited in Ewen & Bucher, 2013). The major purpose of the RCA process is to prevent the damage from happening again.
This damage may relate to loss of function or intellectual impairment. The RCA team is urged to keep asking “why” to reduce harm and prevent recurrence after an incident is declared sentinel (Croteau, 2010). The root cause is analyzed after extensive research by team members which includes reviewing all past documents. An incident based on a delayed primary wound closure is worth mentioning here to demonstrate the importance of RCA. This was the kind of incident which involved future risk and so, it necessitated use of the RCA process. An older female after going through a surgery for excision of a large seroma got admitted to the hospital again for serious post-wound infection.
The root cause was identified as absence of information because interrogation of nurses revealed that no documentation was made on packing count in the clinical note. This was a systematic mistake and research also reveals that “most sentinel events result from systemic problems” (Sorbello, 2008). This incident demanded an immediate RCA because of a positive wound culture observed in the patient (Ewen & Bucher, 2013). References: Anderson, B., Fagerhaug, T., & Beltz, M.
(2010). Root Cause Analysis and Improvement in the Healthcare Sector. Milwaukee, WI: ASQ Quality Press. Croteau R. J. (2010). Root Cause Analysis in Health Care: Tools and Technique (4th ed. ). IL: Joint Commission Resources. Ewen, B.M. & Bucher, G. (2013). Root Cause Analysis: Responding to a Sentinel Event. Home Healthcare Now, 31(8), 435-443. Retrieved from http: //www. nursingcenter. com/lnc/CEArticle? an=00004045-201309000-00006&Journal_ID=2695880&Issue_ID=1600730 Sorbello, B. (2008). Responding to a sentinel event. ANA, 3(10). Retrieved from http: //www. americannursetoday. com/responding-to-a-sentinel-event/