Paper Example on Root Cause Analysis: Identifying Health Challenges

Introduction

The root cause analysis refers to the procedure of identifying the primary causes or source of a given health problem. In the Clinical practice, the root cause analysis is often used to examine the differences that exist between the desired state of health of a patient or social issue and the outcome or what is taking place at a given time (the current situation) (Andersen, Fagerhaug, & Beltz, 2009). In the medical examination, the root cause analysis aids in the identification of challenges that needs to be addressed in the process of treatment to achieve the vision (Andersen, Fagerhaug, & Beltz, 2009). Conducting root cause analysis helps in the help in identifying the root causes and the sources of a health problem, a situation which enhances the best and efficient strategies to overcome it. In the treatment or surgical processes, conducting root-cause analysis dictates the procedures that need to be taken to enhance successful outcomes. In addition, carrying out a root-cause analysis can reveal the kinds of medication that need to be administered.

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Steps in Conducting Root Cause Analysis

Step 1: Identification of Possible Causal Factors

The process of identifying the causal factors involves the situational analysis whereby there is the collection of relevant data needed to enhance the understanding of the present situation (Andersen, Fagerhaug, & Beltz, 2009). In most cases, the data collected or formulated can be applied in the identification of the causal factors; different things that contribute or cause health complications. To accurately identify the causal factors, there is the need to analyze the sequence of events that led to the problem, the conditions that enabled the problem to happen as well as the other related problems that co-exist with the central problem or those problems that might contribute to it (Andersen, Fagerhaug, & Beltz, 2009).

Step 2: Identification of the Root Cause of the Problem

Step 2 follows the first step, and it involves analysing the sources of the health problem, it usually starts with the causal factors identified in step one. In most cases, the root cause of the health problems is coupled to the obvious causes (Andersen, Fagerhaug, & Beltz, 2009). Therefore, it is important for medical practitioners to dig deeper and continue to ask different questions until all the responses are exhausted. There are different methods used in the identification of the root cause of a given health problem (Andersen, Fagerhaug, & Beltz, 2009). One method is the construction of a root cause tree. In most cases, one should start with the problem and continue to brainstorm causal factors for the problem by asking various questions. Succinctly, there is the need to connect different ideas in the logical progression and effect order until one arrives at the root cause of the problem (Andersen, Fagerhaug, & Beltz, 2009).

Step 3: Identification of Communication Challenges

After the identification of the root cause of the problem, there is the need to identify the communication challenges that may influence the treatment of a given medical condition or surgical procedures (Andersen, Fagerhaug, & Beltz, 2009). There are different ways of addressing communication challenges. One of the best ways to share communication challenges is to share findings of other root causes with leaders and local authorities or even the organizations that are capable of addressing them (Andersen, Fagerhaug, & Beltz, 2009).

Step 4: Prioritizing the Communication challenges

While carrying out root cause analysis, there is a high possibility of identifying more than one communication challenges. Therefore, there is the need to decide on which challenge to address first. To achieve the above scenario, there is the need to rank the root causes in order, starting with the main ones, in other words, key communication problems should be addressed first (Andersen, Fagerhaug, & Beltz, 2009). In the determination of ranks, one should consider the difficulty of reaching the audiences that are associated with the communication challenges, as well as the potential effects of addressing these challenges. On the other hand, there is a need to assess the mandate attached to the funding (Andersen, Fagerhaug, & Beltz, 2009). If more two or more causal factors are linked to the root cause, in other words, in other words, if one root cause is the source or origin of numerous causal factors, it means that addressing the root cause can have far-reaching impacts.

Step 5: Deciding on the one Causal Factor

In this step, one is able to identify and concentrate on the one causal factor in an attempt to facilitate the treatment of a given health problem or a disease (Andersen, Fagerhaug, & Beltz, 2009). In this stage, the medical practitioners will be able to decide on the best treatment or surgical approach for the best possible outcome.

Step 6: Summarizing the Information in a Format in Order To Engage the Staff

The final step of the root causes analysis to create a summary of the entire information in a format that engages the staff as well as other important parties or key stakeholders (Andersen, Fagerhaug, & Beltz, 2009). The organization of the information should be aligned with the flow of events as well as other processes involved in the identification of causal factors. The arrangement of information can enable the staff in the recognition of moments within different events.

Causative and Contributing Factors That Led To the

Sentinel Event Outcome

The root cause analysis can be used to describe the contributions and the causative factors that led to the condition of Mr. B. The outcome of the treatment process can be related to the outcome that was evident in the whole process of medical intervention. Mr. B complained of severe pain, and when asked to describe the pain in the scale of one to ten, he chose ten indicate indicating that he was in severe pain. The subsequent analysis indicated was therefore employed by the medical professionals to aids in the determination of the causal factors of the pain. To be specific, the severe pain concentrated on the left leg as well as the hip. The above case was identified through the preliminary assessments that were conducted immediately after the arrival of the patient in the hospital. The determination of causal factors involved assessing the heart rate, blood pressure as well as the overall body temperature; all were found to be in the normal range. With the subsequent analysis to determine the root cause of the pain in the left leg and hip bone, the triage nurse realized that the left leg was shorter compared to the right one and it could not exhibit the motion or movement as the right leg. In other words, it could not operate normally as expected. Once the above complication was identified, there was the prescription of various drugs including oxycodone and atorvastatin. Later, Diazepam IVPB5mg was prescribed, but still, there was no significant impact. Additionally, hydromorphone was given to the patient to enhance the level of sedation. With the realization of a shorter left leg, the doctors and nurses knew that it was the main causative agent of pain, hence the doctor tried to manipulate and correct the right leg and the hip bone. Again, the blood pressure, temperature, and oxygen saturation were monitored to determine to identify the root cause of the pain. All the above tests, as well as the operational process, were done to determine the root cause of Mr. B's problem ones he was admitted to the emergency room within the hospital.

The rating of the pain, measurement of body temperature, blood pressure as well as the surgical operation to correct the hip bone were all done to determine the root cause of Mr. B's problem. In many cases, the diagnosis processes are the steps towards the determination of the root cause of different health conditions and complications related to an individual condition.

In the second stage of Root cause analysis, the medical professionals, Nurse J and Dr T engaged in different medical processes to determine the actual root cause of Mr. B's complications. Ones Mr. B was admitted in the emergency unit, the analysis concentrated on the assessment of pain and the possible causes. In most cases, the medical team engages in the tests to determine the treatment procedures or the medications to administer. The tests, however, follow the recommended procedures and processes the leads to the accuracy in the diagnosis processes. Mr. B's pain was highly rated thus it required a lot of attention and careful examination to rightfully determine the causes. In other words, the evaluation of the pain involved analysis of the tissue, bone and nerve destructions that are highly possible with the type of injury exhibited by the Mr. B. In the medical practice as well as the treatment processes, the assessment of pain involves the analysis of past and resent medication. In the above scenario, Nurse J and Doctor T used the past and present medication to aid in the determination of the root cause of Mr. B's problem. The assessment of pain was frequently administered to ensure that accurate treatment is administered. The pain revealing medication facilitated the assessment as the doctor was able to rectify the hip and the left leg. The drugs were administered to achieve maximum comfort in the process of analysis. In the process of treatment, different equipment was used to test different conditions with an attempt to establish the root cause of the pain in Mr. B's left leg and the hip bone. The electronic monitoring and evaluation process aids in the process of assessment. In addition, physical examination was also used to determine the root cause of the pain. Through observation, nurse J was able to observe the fact that Mr. B's left foot was shorter than the right one.

From the third step, while trying to identify the root cause of a medical problem, always, there is the need to identify the communication challenges that may impact the entire process of the treatment process (Andersen, Fagerhaug, & Beltz, 2009). In the above scenario, the communication challenges were not fully addressed and as a result, there were complications that resulted as a result of the drug prescriptions. In other words, there was a lack of proper and elaborate follow up in the process of medication. Some of the pain-relieving drugs were frequently administered, a situation that worsens the Mr. B's conditions. Additionally, there was not a proper determination of the pain levels which could have determined the types of drugs to be administered as well as the condition to which they should be administered. The miscommunication among the medical practitioners caused by the numerous admission of other patients led to the ineffective control of the equipment, a situation that complicated the entire process. To ensure proper coordination, nurse J could have concentrated on Mr. J; this could have ensured that everyone acted within their scope for the benefit of the patient.

From the fourth step, there is the prioritization of the communication challenge. Mr.B went to cardiac arrest and as the prescription of the narcotics was a priority. In other words, it was the best action to take at the time. Even though there was a lack of action from LPN, and given the fact that they acted out of their scope, the only option was to administer narcotics. From the fifth step in the root cause analysis, there is the decision on the one causal factor. In the above case, ones the Mr..B was referred to a new facility, it was determined that the brain cells had died and as a result, the clien...