Application of Root Cause Analysis

As you have examined in this course, errors and mishaps, although not frequent, do occur in health services organizations. While the aim is to deliver effective and quality care, errors due to systems processes or inefficient system checks still exist. As a current or future health care administration leader, applying process tools to analyze and determine the causes of such errors will likely impact initiatives aimed at fostering health care quality and safety.

For this Assignment, review the resources for this week that are specific to RCA. Reflect on the AHRQ article regarding factors that may lead to latent error and the New York Times article regarding the doctor who removed the wrong limb from a patient. Think about recommendations you might make to prevent errors such as these from occurring in your health services organization.

The Assignment: (3–4 pages)

  • Briefly summarize the salient facts of the New York Times article.
  • Using the AHRQ table regarding factors that may lead to latent error, assess how each factor might have contributed to the wrong-limb surgery.
  • Qualitatively assess how much each factor contributed to the error.
  • Provide recommendations that you believe would present such an event from occurring again, and explain why you made these recommendations. Be specific and provide examples.

RESOURCES

Ross, T. K. (2014). Health care quality management: Tools and applications. San Francisco, CA: Jossey-Bass.

  • Chapter 5, “Root Cause Analysis” (pp. 161–216)

Agency for Healthcare Research and Quality. (2014). Root cause analysis. Retrieved from https://psnet.ahrq.gov/primers/primer/10/root-caus…

Associated Press. (1995, September 17). Doctor who cut off wrong leg is defended by colleagues. The New York Times. Retrieved from http://www.nytimes.com/1995/09/17/us/doctor-who-cu…

Wu, A. W., Lipshutz, A. K. M., & Pronovost, P. J. (2008). Effectiveness and efficiency of root cause analysis in medicine. Journal of the American Medical Association, 299(6), 685–687.
Note: Retrieved from the Walden Library databases.

Expert Solution Preview

Introduction:
As a healthcare administration leader, it is essential to develop strategies that work towards preventing errors and mishaps in healthcare organizations. The aim is to deliver effective and quality care, with the implementation of process tools to analyze and determine the causes of such errors. This assignment focuses on reviewing the resources for the week, including an AHRQ article regarding factors that may lead to latent error, and a New York Times article regarding a doctor’s surgery mistake. The aim is to make recommendations to prevent such errors from occurring in the future.

1. Briefly summarize the salient facts of the New York Times article.

The New York Times article discusses a medical error that occurred when a surgeon removed the wrong leg of a patient. The article mentioned that the surgeon relied on the patient’s medical records, which had mistakenly marked the wrong leg. The surgery took place despite the efforts of the nursing staff to stop the procedure. The patient underwent the surgery again, where the correct leg was removed. The incident led to a national debate on the quality of healthcare delivery, medical negligence, and malpractice lawsuits.

2. Using the AHRQ table regarding factors that may lead to latent error, assess how each factor might have contributed to the wrong-limb surgery.

The AHRQ table highlights several factors that may lead to latent errors, including communication failures, staffing patterns, and inadequate policies and procedures. These factors could have contributed to the wrong limb surgery in several ways. For example, miscommunication between the doctor and nursing staff led to the surgery taking place despite attempts to stop it. Staffing patterns and inadequate policies and procedures could have contributed to the incorrect labeling of the patient’s medical records, leading to the surgery on the wrong leg.

3. Qualitatively assess how much each factor contributed to the error.

Each factor mentioned in the AHRQ table could have played a role in contributing to the error, but the miscommunication between the doctor and nursing staff played a vital role. It led to the surgery taking place despite efforts to stop it, indicating a breakdown in communication and a lack of effective communication policies and procedures.

4. Provide recommendations that you believe would prevent such an event from occurring again, and explain why you made these recommendations. Be specific and provide examples.

To prevent such an event from happening again, the healthcare organization needs to focus on improving communication channels between doctors and nursing staff. Policies and procedures should be in place for effective communication, including protocols for reviewing and verifying patient information before surgery. Medical records should be easily accessible and clearly marked to prevent any confusion. Simple and effective checks and balances can also be put in place to cross-check the patient’s name, age, sex, and the surgical limb before executing surgery. Additionally, the implementation of technologies such as barcode scanning or Radio Frequency Identification (RFID) would also help reduce the likelihood of such errors.

Conclusion:
The incident of the medical error in removing the wrong leg from a patient underscores the importance of preventing such errors in healthcare organizations. Effective communication between doctors and nursing staff, clear and easily accessible medical records, and simple checks and balances with the aid of technology can help prevent similar events from taking place in the future. As healthcare administration leaders, it is our responsibility to implement strategies that aim to improve the quality and safety of healthcare delivery.

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

WU Detail and Dynamic Complexity Discussion Nursing Assignment Help

Are you overwhelmed by complexity? If so, you are not alone. Peter Senge notes that people are now able to “create far more information that anyone can absorb,” and he continues to say that the “scale of complexity is without precedent” (2006, p. 69). This “detail” complexity can make managing

Pediatric Health & Medical Worksheet Nursing Assignment Help

Provider: i. Questions for HPI When did these symptoms begin? Is the child experience exercise intolerance? Any shortness of breath/signs of respiratory distress? History of genetic conditions? ii. Questions for ROS Poor feeding? Any newborn cardiac concerns? Previous cardiac history? Any pain, weakness, coldness to the extremities? Fluid retention? Cough

Health & Medical Capital Budgeting at Cleveland Clinic Nursing Assignment Help

Respond to each of the following prompts or questions: Using the information provided in the Los Reyes Hospital case study from Module Three, what capital expenditures may the selected departments need to budget? Considering the organization you selected, what is a capital expenditure that may be needed that would result

NVCC Service Implementation and Elements of Financial Nursing Assignment Help

Instructions: Part 1 1.Read Chapter 10, Capko. -Critique either Dr. Grainger’s or Mid-South Pulmomary Specialists efforts in developing  new services. -What lessons did you learn as related to new service development?   -List three main items which you must address before implementing a new service.  Instructions: Part 2 -The physicians

Healthcare is reimbursed in a variety of ways. The Nursing Assignment Help

Healthcare is reimbursed in a variety of ways. The prospective payment method is one of those ways. This paper will be about the prospective payment method where diagnosis-related groupings (DRGs) forms the basis for payment. Research and explain the origin, purpose, and description of DRGs. Include what payment is based on.

NUR 630 FIU Impact on Healthcare Systems and Public Health Nursing Assignment Help

Autism Spectrum Disorder, Intellectual Disabilities, or Childhood-Onset Schizophrenia In recent years, there have been reports linking autism to vaccinations. After studying Module 5: Lecture Materials & Resources, address the following in a well-written discussion post: Explain the controversy regarding vaccines as a possible cause of autism spectrum disorder. Does the