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Quality Improvement

Root Cause Analysis (RCA)

Unit 2 Lesson 2b

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Student Learning Outcomes

Define RCA
Describe how RCA is used to ensure quality
Explain the various methods used in RCA

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Root Cause Analysis (RCA)

Structured method used to identify the underlying causes of incidents or problems in healthcare settings
Retrospective (looking back) approach to error analysis
Aims

Identify what happened
Determine how it happened
Understand why it happened

(Lloyd et al., 2023)

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Root Cause Analysis (RCA)

Goal: Prevent similar incidents from occurring in the future.

Focus: Systems and processes that caused the incident rather than individual blame.

(Lloyd et al., 2023)

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Key characteristics of RCA

Systematic and comprehensive investigation
Focuses on underlying causes, not just immediate factors
Involves a team-based approach
Uses various tools and techniques to analyze data
Results in practical recommendations for improvement
Emphasizes learning from errors to enhance client safety

(Lloyd et al., 2023)

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Critical Thinking Question

A medication error has occurred in your unit, resulting in a client receiving the wrong dose of a drug. As the nurse manager, you decide to conduct a Root Cause Analysis.

How would you explain to your team what RCA is and why it's important in this situation?

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Using RCA for Quality Improvement

Incident investigation

Used to analyze adverse events, near misses, and sentinel events

System improvement

Identifies weaknesses in processes and systems

Risk reduction

Helps develop strategies to mitigate (reduce) future risks

(Lloyd et al., 2023)

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Using RCA for Quality Improvement continued…

4. Culture of safety

Promotes a blame-free environment focused on learning

5. Continuous improvement

Supports ongoing efforts to enhance client care

(Lloyd et al., 2023)

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RCA Process in Healthcare

Identify and prioritize events for investigation
Gather a multidisciplinary team
Collect data and evidence related to the event
Map the sequence of events
Identify contributing factors and root causes

(Lloyd et al., 2023)

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RCA Process in Healthcare

6. Develop and implement action plans

7. Measure the effectiveness of implemented changes

8. Share lessons learned across the organization

(Lloyd et al., 2023)

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Critical Thinking Question

A nurse manager is leading a quality improvement initiative following a series of client falls on their unit. How should the nurse manager use Root Cause Analysis (RCA) to ensure quality improvement?

Conduct an RCA to identify patterns and underlying system factors contributing to the falls.
Use the RCA to reinforce disciplinary measures for staff involved in the incidents.
Apply RCA results to develop a checklist for staff compliance monitoring.
Implement RCA findings by adjusting unit workflow to reduce staff workload.

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Methods Used in RCA

Five Whys Technique
Repeatedly ask "Why?" to dig deeper into causes
Examples

Why did the client fall? (They slipped)
Why did they slip? (The floor was wet)
Why was the floor wet? (A spill wasn't cleaned up)
Why wasn't the spill cleaned? (No staff were available)
Why were no staff available? (Understaffing during shift change)

Helps identify multiple contributing factors

(Lloyd et al., 2023)

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Five Whys Technique Example: Medication Error

Why was the wrong medication administered? (Nurse picked up the wrong vial)
Why did the nurse pick up the wrong vial? (Similar packaging to correct medication)
Why were similar medications stored together? (No clear storage protocol)
Why was there no clear storage protocol? (Lack of standardized medication management system)
Why was there no standardized system? (Insufficient focus on medication safety in the organization)

Application: Useful for tracing a clear path from the incident to underlying systemic issues.

(Lloyd et al., 2023)

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Methods Used in RCA

2. Ishikawa (Fishbone) Diagram

Visual tool to categorize potential causes
Main categories often include:

People
Processes
Equipment
Environment
Materials
Management

(Lloyd et al., 2023)

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Methods Used in RCA continued…

2. Ishikawa (Fishbone) Diagram

Helps organize and display multiple contributing factors
Useful for complex issues with many potential causes
Example

Increase in number of readmissions to the hospital within 24 hours

(Lloyd et al., 2023)

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Ishikawa (Fishbone) Diagram Example: Surgical Site Infection

People: Insufficient hand hygiene, inadequate surgical technique
Process: Rushed pre-op preparation, prolonged surgery duration
Equipment: Improperly sterilized instruments, malfunctioning HVAC system
Environment: Overcrowded operating room, high traffic in recovery area
Materials: Contaminated surgical drapes, expired antiseptic solution
Management: Understaffing, lack of infection control protocols

Application: Helps visualize multiple contributing factors across various aspects of healthcare delivery.

(Lloyd et al., 2023)

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Methods Used in RCA: Examples and Applications

Application: Helps visualize multiple contributing factors across various aspects of healthcare delivery.

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Methods Used in RCA

3. Cause and Effect Analysis

Similar to Fishbone Diagram but more detailed
Steps:

Define the problem clearly
Identify major factors involved
Identify possible causes for each factor
Analyze the diagram to identify root causes

Allows for a comprehensive view of the problem and its causes

(Lloyd et al., 2023)

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Cause and Effect Analysis Example: Client Fall in Hospital

Client factors

Age, mobility issues, medication side effects

Staff factors

Workload, training, communication

Environmental factors

Lighting, floor surface, bed height

(Lloyd et al., 2023)

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Cause and Effect Analysis Example: Client Fall in Hospital continued…

Equipment factors

Faulty bed rails, lack of assistive devices

Policy factors

Fall risk assessment procedures, rounding frequency

(Lloyd et al., 2023)

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Cause and Effect Analysis Example: Client Fall in Hospital continued…

Policy factors

Fall risk assessment procedures, rounding frequency

Application: Provides a comprehensive view of interrelated factors contributing to complex incidents.

(Lloyd et al., 2023)

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Methods Used in RCA

4. Failure Mode and Effects Analysis (FMEA)

Method to identify potential failures before they occur
Steps:

Identify potential failure modes
Determine the effects of each failure
Identify possible causes
Evaluate the risk (severity, occurrence, detection)
Develop and implement actions to reduce risk

Useful for preventing adverse events before they happen

(Lloyd et al., 2023)

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Failure Mode and Effects Analysis (FMEA) Example: Preventing Medication Errors in Chemotherapy Administration

Steps:

Identify potential failures

Wrong drug, wrong dose, wrong client, wrong route

Effects

Severe toxicity, ineffective treatment, client harm

Causes

Look-alike drugs, calculation errors, client misidentification

Risk evaluation

High severity, moderate occurrence, low detection

(Lloyd et al., 2023)

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Failure Mode and Effects Analysis (FMEA) Example continued…

5. Actions

Implement barcode scanning, require double-checks, standardize labeling

Application: Proactively identifies and mitigates risks in high-stakes processes.

(Lloyd et al., 2023)

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Methods Used in RCA

5. Timeline Analysis

Chronological mapping of events leading to the incident
Includes:
Actions taken
Communications
Environmental factors
Equipment issues

(Lloyd et al., 2023)

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Methods Used in RCA

5. Timeline Analysis

Helps identify gaps in processes and critical points where interventions could have prevented the incident
Useful for understanding the sequence of events and identifying multiple contributing factors

(Lloyd et al., 2023)

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Timeline Analysis Example: Delayed Diagnosis of Sepsis

Application: Identifies critical points where interventions could have changed the outcome, especially useful in cases involving multiple caregivers or extended timeframes.

Client admission with fever and elevated heart rate	Vital signs recorded but not acted upon	Shift changes with incomplete handover	Lab results showing elevated white blood cell count	Delay in physician review of results	Client condition deteriorates	Sepsis diagnosis made and treatment initiated

(Lloyd et al., 2023)

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Critical Thinking Question

Your hospital conducts an RCA following a serious client fall. Team members have differing views on the use of '5 Whys' technique and the Ishikawa (Fishbone) methods.

How would you explain the differences between these two methods, and in what situations might one be more appropriate than the other?

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Answer: You could explain that both the '5 Whys' and Ishikawa diagram are methods used in RCA, but they have different approaches and strengths:

The '5 Whys' technique involves asking "Why?" repeatedly (typically five times) to drill down to the root cause. It's simple, quick, and good for straightforward problems. For example: Why did the client fall? - Because they slipped. Why did they slip? - Because the floor was wet. Why was the floor wet? - Because of a leak in the ceiling. Why was there a leak? - Because of poor maintenance. Why was maintenance poor? - Because of inadequate scheduling and oversight.

The Ishikawa (Fishbone) diagram is a visual tool that helps identify multiple contributing factors to a problem. It categorizes potential causes into groups (e.g., People, Process, Equipment, Environment). It's more comprehensive and better for complex issues with multiple contributing factors.

In the case of a client fall, the '5 Whys' might be more appropriate if there seems to be a clear sequence of events leading to the fall. However, if the fall appears to have multiple contributing factors (e.g., client factors, environmental factors, staffing issues), the Ishikawa diagram might be more suitable as it allows for a broader exploration of potential causes.

The choice between methods often depends on the complexity of the problem, the time available for analysis, and the team's familiarity with the tools. Sometimes, using both methods can provide a more comprehensive understanding of the issue.

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Comparison of RCA Methods

Method	Strengths	Best Used For
Five Whys	Simple, quick, identifies root causes	Straightforward incidents with clear causal chains
Ishikawa Diagram	Visual, comprehensive, categorizes causes	Complex issues with multiple contributing factors
Cause and Effect Analysis	Detailed, shows relationships between causes	In-depth analysis of multifaceted problems
FMEA	Proactive, prioritizes risks	High-risk processes, preventive analysis
Timeline Analysis	Shows sequence of events, identifies gaps	Incidents involving multiple steps or providers

(Lloyd et al., 2023)

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Choosing the Right RCA Method

Consider

Complexity of the incident
Available time and resources
Team expertise and familiarity with methods
Nature of the problem (e.g., one-time incident vs. recurring issue)
Organizational culture and preferences

(Lloyd et al., 2023)

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Choosing the Right RCA Method

Best practice: Combine methods for a comprehensive analysis

Example:

Analyze to map event
Apply chosen method
Diagram to dig deeper

(Lloyd et al., 2023)

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Critical Thinking Question

A nurse is part of a team investigating a series of medication errors in the pediatric unit. The errors seem to be related to various factors including staff training, medication labeling, and communication issues. Which RCA method should the nurse suggest to analyze this complex situation?

Five Whys Technique
Cause and Effect Analysis
Timeline Analysis
Failure Mode and Effects Analysis (FMEA)

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References

Lloyd, S., Olley, R., Milligan, E., Aish, K., Barnes, A., Craig, J., Evans, J., ferrier, J.a., Khalil, H., Lakhani, A., Long, K., Murray, M., Sequeira, A.R. & Mackenzie-Stewart, R. (2023). Leading in Health and Social Care. Griffith University; Pressbooks. https://oercollective.caul.edu.au/leading-in-health-and-social-care/

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