d5 DD

| 26 | THE JOURNAL OF LEGAL NURSE CONSULTING

FEATURE

WHAT IS A ROOT CAUSE ANALYSIS? The Joint Commission (2015) defines root cause analysis (RCA) as “a pro- cess for identifying the basic or causal factor(s) underlying variation in perfor- mance. Variation in performance can (and often does) produce unexpected

and undesired adverse outcomes” (p. 1). Ultimately, RCAs are used to determine why an unexpected or unintended out- come occurred and “to identify system vulnerabilities so that they can be elim- inated or mitigated” (National Patient Safety Foundation, 2015, para. 4). By using RCAs to evaluate the events, haz- ards, and vulnerabilities in their systems

of care, organizations and individuals can gain an understanding of what hap- pened and why and then identify actions to prevent a recurrence. A root cause analysis helps healthcare organizations to better understand what circumstances led to the undesirable outcome or near miss, what safety rules were violated, and where individual providers and

Root Cause Analysis: A Pediatric Case Study Katherine Haney, MSN, RN-BC

A root cause analysis (RCA) is a retrospective, structured investigation of an adverse event, near miss, or sentinel event. By using RCAs to evaluate the events, hazards, and vulnerabilities in their systems of care, organizations and individuals can gain an understanding of what happened and why and then identify actions to prevent a recurrence. A root cause analysis helps healthcare organizations to better understand what circumstances led to an undesirable outcome or near miss, what safety rules were violated, and where individual providers and the organization as a whole failed. Adverse events in healthcare come from a mix of active failures, latent conditions, and contributory factors.

Keywords: Root cause analysis, system breakdown, process error, pediatrics, risk management

ISSN 2470-6248 | VOLUME 31 | ISSUE 4 | WINTER 2020 | 27 |

the organization as a whole failed. It is important to note RCAs generally focus on organization-level system and process failures, not on individual-level performance failures “since individual performance is a symptom of larger systems-based issues” (National Patient Safety Foundation, 2015, para. 4).

Mapping out events in a chronological manner is one way to review the care provided. However, in RCA methodol- ogy, events are grouped together based on categories. This allows different insight into what exactly occurred and why. One main advantage to group- ing events into categories is it clearly demonstrates what failures occurred at the system and organizational level that contributed to the adverse outcome, near miss, or harm to a patient. Adverse events in health care almost never occur because of one, singular cause. They are typically a combination of active failures and latent conditions that align and slip through any safety mechanisms in place (The Joint Commission, 2015). Active failures are “errors occurring at the point of interface between humans and a com- plex system” such as an electronic health record software program or an auto- mated medication dispensing system (Agency for Healthcare Research and Quality, 2019, para. 1). Latent condi- tions are “the hidden problems within health care systems that contribute to adverse events,” e.g., no defined stan- dard workflow (Agency for Healthcare Research and Quality, 2019, para. 1). This systems approach “is one of the most widely used retrospective methods for detecting safety hazards” in health- care organizations across the country (Agency for Healthcare Research and Quality, 2019, para. 1).

HOW IS AN RCA PERFORMED? In a high reliability, patient safe- ty-focused organization, RCAs are performed by a team made up of various members of leadership, includ-

ing representatives from Quality, Risk Management, Nursing, and ancillary departments as well as ad hoc members based on the type of event and where it occurred. Additionally, members of the care team with personal knowledge of the processes and systems involved in the event under investigation should also participate. Root cause analyses performed by the facility are typical- ly peer review protected (and thus non-discoverable) during litigation.

There are four steps to performing a root cause analysis.

1. Identify what happened to the patient. 2. Determine what should have

happened. 3. Determine the causes. Causes are

categorized into six different groups, which will be discussed further below: communication, training, fatigue/scheduling, environment/ equipment, rules/policies/procedures and barriers. The RCA team methodically reviews each category to determine the root causes and contributing factors. Root causes are “the underlying process and system issues” identified by analyzing the contributing factors, “the situations, circumstances or conditions that increased the likelihood of the event” (Centers for Medicare and Medicaid Services, n.d.).

4. Develop causal statements. These statements explain how the contributory factors brought about the adverse outcome.

To better understand these steps, consid- er the following fictitious case scenario.

WHAT HAPPENED? Liam is an eight-year-old, right-hand dominant male who is brought into the county emergency department after collapsing on the baseball field. It is a hot day in the middle of sum- mer, and his parents report he did not break much for water during the soccer game. Liam is difficult to arouse, has dry mucous membranes, and a general ill appearance. His lab results show severe dehydration, and the registered nurse (RN) starts an intravenous (IV) infusion of five percent dextrose and 25 percent normal saline, plus 20 mEq per liter of potassium in his right hand. Liam’s mental status starts to improve over the next few hours, and he is conversing with his parents. He tells his nurse his hand hurts where the IV is running. The nurse explains the med- icine they are giving may have a slight burn feeling. When the medication is complete, the RN switches him over to normal saline per orders. The RN sees his right hand is blistered, tense, and discolored. He has a decreased radi- al pulse, and capillary refill is greater than three seconds. Unfortunately, the infiltrate site progresses and results in necrosis to the tissue and major loss of function. Liam is no longer able to use his right hand for writing, throwing a ball, and activities of daily living.

WHAT SHOULD HAVE HAPPENED? A thorough review of the medical records revealed the RN did not cor- rectly place a large bore IV in a large vein above the wrist as directed in the

A root cause analysis helps healthcare organizations to better understand what circumstances led to the undesirable outcome or near miss…

| 28 | THE JOURNAL OF LEGAL NURSE CONSULTING

FEATURE

ment had been performed, the RN may have been able to identify the infiltrate sooner and intervene, thereby reducing the risk of tissue necrosis and loss of function. This is a failure of the RN to assess the site of pain that was communi- cated by the patient.

Training: This category asks, “Was the staff training adequate?,” “Were the results of training monitored over time?,” and “Did the organization provide adequate training programs

for staff with the intent of them performing their tasks without

errors?” (National Patient Safety Foundation, 2015, p. 32). In

the case mentioned, the RCA team requested education documentation from the organization regarding IV infiltrations, including the actual education module/ content, number of learners

who have taken the module and when, competency testing

scores, etc. In reviewing this information, the RCA team noted

up-to-date, good quality content but noticed a high number of learners took the module in the recent past. This may suggest the organization was having an increase in IV infiltra- tions and was attempting to reactively (rather than proactively) educate staff regarding prevention, recognition, and treatment. This is a failure of the organization to enforce its education/ training requirements and ensure its RNs met competency before an adverse event occurred. The content and quality of the educational materials was good, but the education and competency testing were not executed the way the organiza- tion intended.

Fatigue/scheduling: For this category, the RCA team considers questions such as “Did scheduling allow personnel to have adequate sleep?,” “Was fatigue properly anticipated?,” and “Were there sufficient staff on hand for the patient

organization’s policy for the administra- tion of caustic medication. Additionally, the IV site, skin, and tolerance were not assessed every two hours as required. Lastly, when the RN notified the emergency department physician of the infiltrate, a vascular or plastic surgery consult was not placed as outlined in the organization’s policy.

workload at the time?” (National Patient Safety Foundation, 2015, p. 32). Looking at the emergency department census for the shift in question, the RCA team discovered it was a very busy Saturday afternoon. This particular nurse had three other patients (includ- ing a myocardial infarction patient) while caring for Liam. The RN was working a 12-hour shift (the second one in a row) with a higher than average and complex patient load, increasing the chanc- es an error would be made or a policy and procedure not followed.

Equipment/Environment: This cat- egory asks the RCA team to focus on questions such as “Was there a docu- mented safety review performed on the equipment provided?” and “Was there adequate equipment to perform the work process?” (National Patient Safety Foundation, 2015, p. 33). In this fic- tional scenario, the RCA team asked for the preventative maintenance log as well as the audit trail for the IV pump that was used to infuse the medication. A review of these documents revealed the organization followed its own require- ments for scheduled quality checks and the pump performed as programmed to deliver the drug at the appropriate rate. No deviations from standards within the equipment category were found.

Questions to consider in this case from the environmental perspective include where were the room locations of the RN’s other assigned patients and was the RN having to traverse the entire department to see all of these patients or were they placed in adjacent rooms from each other. A copy of the emergen- cy department’s floor plan was requested and showed all assigned patients were within close proximity of each other except for the myocardial infarction patient who was placed in the trauma bay across the department from Liam. Because the nurse had to care for patients in two separate areas of the department, this took away from time the RN could

WHAT WERE THE CAUSES, AND HOW DID THEY CONTRIBUTE TO THE OUTCOME (CAUSAL STATEMENTS)? Communication: This category asks questions like “Was communication between staff adequate?” and “Was a ‘readback’ or confirmation message utilized?” (National Patient Safety Foundation, 2015, p. 31-32). In the case scenario, the RN documented Liam’s complaints of pain at the IV site and the education provided to him and his family regarding the side effects of a potassium IV infusion. Unfortunately, Liam’s complaint of pain to the RN did not prompt the RN to perform an assessment of the IV site. If an assess-

ISSN 2470-6248 | VOLUME 31 | ISSUE 4 | WINTER 2020 | 29 |

have been assessing and intervening with the infiltrated IV.

Rules/Policies/Procedures: This category focuses on questions such as “Were there written policies and proce- dures that addressed the work processes related to the adverse event?,” “Were these policies and procedures consistent with state and national guidelines?,” and “Were the relevant policies actually used on a day-to-day basis?” (National Patient Safety Foundation, 2015, p. 34). Upon reviewing the organization’s pol- icy and procedure for IV infiltrations, the RCA team learned the provider is responsible for consulting wound care, vascular, and plastic surgery specialties when an IV infiltration has occurred and caused damage. In comparison, Liam’s medical records showed only wound care was consulted after identi- fication of the injury. The wound care RN assessed Liam and, at that time, spoke with the emergency department physician about the need for additional consults. This resulted in a five-hour delay of specialty care. The Medical Staff Rules, Regulations, and Bylaws for this organization state independent- ly-contracted providers (such as the emergency department physician) are required to follow the policies and pro- cedures outlined by the hospital. This is a failure of the organization to ensure its policies are followed by all members of the care team. Because of this breakdown on a system level, care was delayed resulting in loss of function to Liam’s hand.

Barriers: Lastly, it is important to assess what barriers and controls were involved in an adverse event. Questions to consid- er include, “Were these barriers designed to protect patients, staff, equipment, or the environment?” and “Had these barriers been evaluated for reliability?” (National Patient Safety Foundation, 2015, p. 34). In this case scenario, when the RN scanned the IV solution to hang it, the organization’s barcode medication administration software program gen-

erated a pop-up alert in the electronic medical record advising this was a caus- tic medication. The alert reminded the RN of the potential for serious tissue injury with the medication. Unfortu- nately, the RN dismissed this reminder and did not use it as a tool to help with the assessment process. While there is value in this built-in safety barrier, it is only as good as the human interacting with it. This is a failure of the RN to heed the alert, initiate interventions to reduce the risk posed by administering a caustic medication, and provide additional assess- ment in light of this risk.

SUMMARY In this case study, Liam suffered an IV extravasation of potassium which led to necrosis and loss of function of his dominant right hand. A thorough root cause analysis identified several areas of opportunity for the organization. Clearly defining action items to improve the system or processes and identifying which stakeholder is responsible for each action is the best way to minimize the chance of this type of harm happen- ing again. First, nursing at this facility needs reeducation around communica- tion and reassessment when a patient verbalizes pain and discomfort. Reed- ucation should also include steps to take to prevent an IV extravasation as well as appropriate interventions once one is recognized - as already outlined in the facility’s existing policy. Nursing should also be reminded the electronic alerts and barriers are there to prevent patient harm and should not be quickly dismissed. Second, the facility should focus on enforcing compliance with education. By ensuring all required staff complete assigned learnings, admin- istration can further sort out whether this is truly a lack of education issue or a behavioral compliance issue. Next, the facility should look at nurse-to-patient ratios, how to better balance patient acuity in each nurse’s assignment, and ways to ensure each nurse’s patients

are in close proximity. This would have prevented the RN from having several high acuity patients at the same time during the shift in different areas of the department. Once the action items have been completed, the RCA team should schedule random audits on the process throughout the year to ensure action items have been addressed and overall compliance has increased. By periodically evaluating and analyzing the effectiveness of the RCA action items, the facility can ensure the RCA was productive and meaningful and can also continue to reduce the risk of patient harm.

REFERENCES: Agency for Healthcare Research and Quality. (2019). Root cause analysis. https://psnet.ahrq. gov/primer/root-cause-analysis

Centers for Medicare and Medicaid Services. (n.d.). Guidance for performing root cause analysis (RCA) with performance improvement projects (PIPs). https://www. cms.gov/Medicare/Provider-Enrollment- and-Certification/QAPI/Downloads/ GuidanceforRCA.pdf

National Patient Safety Foundation. (2015). RCA2: Improving root cause analyses and actions to prevent harm. Institute for Healthcare Improvement. http://www.ihi.org/resources/ Pages/Tools/RCA2-Improving-Root-Cause- Analyses-and-Actions-to-Prevent-Harm.aspx.

The Joint Commission. (2015). Root cause analysis in health care: Tools and techniques (5th ed.). Joint Commission Resources. https://www.jcrinc.com/-/media/deprecated- unorganized/imported-assets/jcr/ default-folders/items/ebrca15samplepdf.pdf.

Katie Haney is a masters prepared, licensed and board-certified Registered Nurse in the state of California with a background in Emergency Room nursing

and expertise in Quality and Risk Manage- ment. She currently manages the Risk & Safety Program for a 350-bed acute care hospital in Southern California. Katie frequently serves as an expert witness for root cause analysis, risk and quality issues.

Copyright of Journal of Legal Nurse Consulting is the property of American Association of Legal Nurse Consultants and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

| 26 | THE JOURNAL OF LEGAL NURSE CONSULTING

FEATURE

WHAT IS A ROOT CAUSE ANALYSIS? The Joint Commission (2015) defines root cause analysis (RCA) as “a pro- cess for identifying the basic or causal factor(s) underlying variation in perfor- mance. Variation in performance can (and often does) produce unexpected

and undesired adverse outcomes” (p. 1). Ultimately, RCAs are used to determine why an unexpected or unintended out- come occurred and “to identify system vulnerabilities so that they can be elim- inated or mitigated” (National Patient Safety Foundation, 2015, para. 4). By using RCAs to evaluate the events, haz- ards, and vulnerabilities in their systems

of care, organizations and individuals can gain an understanding of what hap- pened and why and then identify actions to prevent a recurrence. A root cause analysis helps healthcare organizations to better understand what circumstances led to the undesirable outcome or near miss, what safety rules were violated, and where individual providers and

Root Cause Analysis: A Pediatric Case Study Katherine Haney, MSN, RN-BC

A root cause analysis (RCA) is a retrospective, structured investigation of an adverse event, near miss, or sentinel event. By using RCAs to evaluate the events, hazards, and vulnerabilities in their systems of care, organizations and individuals can gain an understanding of what happened and why and then identify actions to prevent a recurrence. A root cause analysis helps healthcare organizations to better understand what circumstances led to an undesirable outcome or near miss, what safety rules were violated, and where individual providers and the organization as a whole failed. Adverse events in healthcare come from a mix of active failures, latent conditions, and contributory factors.

Keywords: Root cause analysis, system breakdown, process error, pediatrics, risk management

ISSN 2470-6248 | VOLUME 31 | ISSUE 4 | WINTER 2020 | 27 |

the organization as a whole failed. It is important to note RCAs generally focus on organization-level system and process failures, not on individual-level performance failures “since individual performance is a symptom of larger systems-based issues” (National Patient Safety Foundation, 2015, para. 4).

Mapping out events in a chronological manner is one way to review the care provided. However, in RCA methodol- ogy, events are grouped together based on categories. This allows different insight into what exactly occurred and why. One main advantage to group- ing events into categories is it clearly demonstrates what failures occurred at the system and organizational level that contributed to the adverse outcome, near miss, or harm to a patient. Adverse events in health care almost never occur because of one, singular cause. They are typically a combination of active failures and latent conditions that align and slip through any safety mechanisms in place (The Joint Commission, 2015). Active failures are “errors occurring at the point of interface between humans and a com- plex system” such as an electronic health record software program or an auto- mated medication dispensing system (Agency for Healthcare Research and Quality, 2019, para. 1). Latent condi- tions are “the hidden problems within health care systems that contribute to adverse events,” e.g., no defined stan- dard workflow (Agency for Healthcare Research and Quality, 2019, para. 1). This systems approach “is one of the most widely used retrospective methods for detecting safety hazards” in health- care organizations across the country (Agency for Healthcare Research and Quality, 2019, para. 1).

HOW IS AN RCA PERFORMED? In a high reliability, patient safe- ty-focused organization, RCAs are performed by a team made up of various members of leadership, includ-

ing representatives from Quality, Risk Management, Nursing, and ancillary departments as well as ad hoc members based on the type of event and where it occurred. Additionally, members of the care team with personal knowledge of the processes and systems involved in the event under investigation should also participate. Root cause analyses performed by the facility are typical- ly peer review protected (and thus non-discoverable) during litigation.

There are four steps to performing a root cause analysis.

1. Identify what happened to the patient. 2. Determine what should have

happened. 3. Determine the causes. Causes are

categorized into six different groups, which will be discussed further below: communication, training, fatigue/scheduling, environment/ equipment, rules/policies/procedures and barriers. The RCA team methodically reviews each category to determine the root causes and contributing factors. Root causes are “the underlying process and system issues” identified by analyzing the contributing factors, “the situations, circumstances or conditions that increased the likelihood of the event” (Centers for Medicare and Medicaid Services, n.d.).

4. Develop causal statements. These statements explain how the contributory factors brought about the adverse outcome.

To better understand these steps, consid- er the following fictitious case scenario.

WHAT HAPPENED? Liam is an eight-year-old, right-hand dominant male who is brought into the county emergency department after collapsing on the baseball field. It is a hot day in the middle of sum- mer, and his parents report he did not break much for water during the soccer game. Liam is difficult to arouse, has dry mucous membranes, and a general ill appearance. His lab results show severe dehydration, and the registered nurse (RN) starts an intravenous (IV) infusion of five percent dextrose and 25 percent normal saline, plus 20 mEq per liter of potassium in his right hand. Liam’s mental status starts to improve over the next few hours, and he is conversing with his parents. He tells his nurse his hand hurts where the IV is running. The nurse explains the med- icine they are giving may have a slight burn feeling. When the medication is complete, the RN switches him over to normal saline per orders. The RN sees his right hand is blistered, tense, and discolored. He has a decreased radi- al pulse, and capillary refill is greater than three seconds. Unfortunately, the infiltrate site progresses and results in necrosis to the tissue and major loss of function. Liam is no longer able to use his right hand for writing, throwing a ball, and activities of daily living.

WHAT SHOULD HAVE HAPPENED? A thorough review of the medical records revealed the RN did not cor- rectly place a large bore IV in a large vein above the wrist as directed in the

A root cause analysis helps healthcare organizations to better understand what circumstances led to the undesirable outcome or near miss…

| 28 | THE JOURNAL OF LEGAL NURSE CONSULTING

FEATURE

ment had been performed, the RN may have been able to identify the infiltrate sooner and intervene, thereby reducing the risk of tissue necrosis and loss of function. This is a failure of the RN to assess the site of pain that was communi- cated by the patient.

Training: This category asks, “Was the staff training adequate?,” “Were the results of training monitored over time?,” and “Did the organization provide adequate training programs

for staff with the intent of them performing their tasks without

errors?” (National Patient Safety Foundation, 2015, p. 32). In

the case mentioned, the RCA team requested education documentation from the organization regarding IV infiltrations, including the actual education module/ content, number of learners

who have taken the module and when, competency testing

scores, etc. In reviewing this information, the RCA team noted

up-to-date, good quality content but noticed a high number of learners took the module in the recent past. This may suggest the organization was having an increase in IV infiltra- tions and was attempting to reactively (rather than proactively) educate staff regarding prevention, recognition, and treatment. This is a failure of the organization to enforce its education/ training requirements and ensure its RNs met competency before an adverse event occurred. The content and quality of the educational materials was good, but the education and competency testing were not executed the way the organiza- tion intended.

Fatigue/scheduling: For this category, the RCA team considers questions such as “Did scheduling allow personnel to have adequate sleep?,” “Was fatigue properly anticipated?,” and “Were there sufficient staff on hand for the patient

organization’s policy for the administra- tion of caustic medication. Additionally, the IV site, skin, and tolerance were not assessed every two hours as required. Lastly, when the RN notified the emergency department physician of the infiltrate, a vascular or plastic surgery consult was not placed as outlined in the organization’s policy.

workload at the time?” (National Patient Safety Foundation, 2015, p. 32). Looking at the emergency department census for the shift in question, the RCA team discovered it was a very busy Saturday afternoon. This particular nurse had three other patients (includ- ing a myocardial infarction patient) while caring for Liam. The RN was working a 12-hour shift (the second one in a row) with a higher than average and complex patient load, increasing the chanc- es an error would be made or a policy and procedure not followed.

Equipment/Environment: This cat- egory asks the RCA team to focus on questions such as “Was there a docu- mented safety review performed on the equipment provided?” and “Was there adequate equipment to perform the work process?” (National Patient Safety Foundation, 2015, p. 33). In this fic- tional scenario, the RCA team asked for the preventative maintenance log as well as the audit trail for the IV pump that was used to infuse the medication. A review of these documents revealed the organization followed its own require- ments for scheduled quality checks and the pump performed as programmed to deliver the drug at the appropriate rate. No deviations from standards within the equipment category were found.

Questions to consider in this case from the environmental perspective include where were the room locations of the RN’s other assigned patients and was the RN having to traverse the entire department to see all of these patients or were they placed in adjacent rooms from each other. A copy of the emergen- cy department’s floor plan was requested and showed all assigned patients were within close proximity of each other except for the myocardial infarction patient who was placed in the trauma bay across the department from Liam. Because the nurse had to care for patients in two separate areas of the department, this took away from time the RN could

WHAT WERE THE CAUSES, AND HOW DID THEY CONTRIBUTE TO THE OUTCOME (CAUSAL STATEMENTS)? Communication: This category asks questions like “Was communication between staff adequate?” and “Was a ‘readback’ or confirmation message utilized?” (National Patient Safety Foundation, 2015, p. 31-32). In the case scenario, the RN documented Liam’s complaints of pain at the IV site and the education provided to him and his family regarding the side effects of a potassium IV infusion. Unfortunately, Liam’s complaint of pain to the RN did not prompt the RN to perform an assessment of the IV site. If an assess-

ISSN 2470-6248 | VOLUME 31 | ISSUE 4 | WINTER 2020 | 29 |

have been assessing and intervening with the infiltrated IV.

Rules/Policies/Procedures: This category focuses on questions such as “Were there written policies and proce- dures that addressed the work processes related to the adverse event?,” “Were these policies and procedures consistent with state and national guidelines?,” and “Were the relevant policies actually used on a day-to-day basis?” (National Patient Safety Foundation, 2015, p. 34). Upon reviewing the organization’s pol- icy and procedure for IV infiltrations, the RCA team learned the provider is responsible for consulting wound care, vascular, and plastic surgery specialties when an IV infiltration has occurred and caused damage. In comparison, Liam’s medical records showed only wound care was consulted after identi- fication of the injury. The wound care RN assessed Liam and, at that time, spoke with the emergency department physician about the need for additional consults. This resulted in a five-hour delay of specialty care. The Medical Staff Rules, Regulations, and Bylaws for this organization state independent- ly-contracted providers (such as the emergency department physician) are required to follow the policies and pro- cedures outlined by the hospital. This is a failure of the organization to ensure its policies are followed by all members of the care team. Because of this breakdown on a system level, care was delayed resulting in loss of function to Liam’s hand.

Barriers: Lastly, it is important to assess what barriers and controls were involved in an adverse event. Questions to consid- er include, “Were these barriers designed to protect patients, staff, equipment, or the environment?” and “Had these barriers been evaluated for reliability?” (National Patient Safety Foundation, 2015, p. 34). In this case scenario, when the RN scanned the IV solution to hang it, the organization’s barcode medication administration software program gen-

erated a pop-up alert in the electronic medical record advising this was a caus- tic medication. The alert reminded the RN of the potential for serious tissue injury with the medication. Unfortu- nately, the RN dismissed this reminder and did not use it as a tool to help with the assessment process. While there is value in this built-in safety barrier, it is only as good as the human interacting with it. This is a failure of the RN to heed the alert, initiate interventions to reduce the risk posed by administering a caustic medication, and provide additional assess- ment in light of this risk.

SUMMARY In this case study, Liam suffered an IV extravasation of potassium which led to necrosis and loss of function of his dominant right hand. A thorough root cause analysis identified several areas of opportunity for the organization. Clearly defining action items to improve the system or processes and identifying which stakeholder is responsible for each action is the best way to minimize the chance of this type of harm happen- ing again. First, nursing at this facility needs reeducation around communica- tion and reassessment when a patient verbalizes pain and discomfort. Reed- ucation should also include steps to take to prevent an IV extravasation as well as appropriate interventions once one is recognized - as already outlined in the facility’s existing policy. Nursing should also be reminded the electronic alerts and barriers are there to prevent patient harm and should not be quickly dismissed. Second, the facility should focus on enforcing compliance with education. By ensuring all required staff complete assigned learnings, admin- istration can further sort out whether this is truly a lack of education issue or a behavioral compliance issue. Next, the facility should look at nurse-to-patient ratios, how to better balance patient acuity in each nurse’s assignment, and ways to ensure each nurse’s patients

are in close proximity. This would have prevented the RN from having several high acuity patients at the same time during the shift in different areas of the department. Once the action items have been completed, the RCA team should schedule random audits on the process throughout the year to ensure action items have been addressed and overall compliance has increased. By periodically evaluating and analyzing the effectiveness of the RCA action items, the facility can ensure the RCA was productive and meaningful and can also continue to reduce the risk of patient harm.

REFERENCES: Agency for Healthcare Research and Quality. (2019). Root cause analysis. https://psnet.ahrq. gov/primer/root-cause-analysis

Centers for Medicare and Medicaid Services. (n.d.). Guidance for performing root cause analysis (RCA) with performance improvement projects (PIPs). https://www. cms.gov/Medicare/Provider-Enrollment- and-Certification/QAPI/Downloads/ GuidanceforRCA.pdf

National Patient Safety Foundation. (2015). RCA2: Improving root cause analyses and actions to prevent harm. Institute for Healthcare Improvement. http://www.ihi.org/resources/ Pages/Tools/RCA2-Improving-Root-Cause- Analyses-and-Actions-to-Prevent-Harm.aspx.

The Joint Commission. (2015). Root cause analysis in health care: Tools and techniques (5th ed.). Joint Commission Resources. https://www.jcrinc.com/-/media/deprecated- unorganized/imported-assets/jcr/ default-folders/items/ebrca15samplepdf.pdf.

Katie Haney is a masters prepared, licensed and board-certified Registered Nurse in the state of California with a background in Emergency Room nursing

and expertise in Quality and Risk Manage- ment. She currently manages the Risk & Safety Program for a 350-bed acute care hospital in Southern California. Katie frequently serves as an expert witness for root cause analysis, risk and quality issues.

Copyright of Journal of Legal Nurse Consulting is the property of American Association of Legal Nurse Consultants and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.