MBA in Health Administration – Coventry University (UK) IIHS495MBA - Health Care Quality & Risk Management in Healthcare Administration Root cause analysis Name of the Student : GAJASINGHA ARACHCHIGE NIPUN SILVA Coventry Registration Number : 14051285 IIHS Registration Number : MHC01006 NIC : 198612600356 Telephone Number : 0718142211 / 0772836179 E-mail Address : nipunsilva@gmail.com Current Semester : Semester Two Year One Date of submission : 10/09/2023 Total word count (2500) : 2493 Facilitator’s Name : Dr. Sridharan Sathasivam Name of Marker/Moderator: Areas of strength: Areas for improvement: General comments (word limits/confidentiality/anonymity issues): Marks: Date: Signature: 3 1. Briefly explain the root causes of this adverse event. Root cause analysis What is a “root cause analysis”? A form of investigation, a troubleshooting method that is used to identify the primary causes of errors or problems or faults. (“Root Cause Analysis,” 2023). It focuses on why, how, and when errors happen, and aims at mitigating the adverse outcomes and stopping the repetition of the errors. It does this by targeting on preventive and corrective actions to be undertaken. Root cause analysis help to improve the quality and safety of an organization / a system etc. Principles of root cause analysis Four main principles are there (What Is Root Cause Analysis?, 2023). - Understand the whole story / complete picture of the incident occurred. - Aim at the root, the underlying cause/s, not the superficial data or the symptoms. - Always plan on how to apply solution to stop the cause recurring. - Whatever is done, do it correctly at the first time. 4 Steps of root cause analysis Four main steps are there (“Root Cause Analysis,” 2023). - Clear identification and description of the problem. - Establishment of a timeline / Arrangement of data in a chronological order. - Identification of the root cause / causes, and separation of root causes from other causes / factors, occurred by chance. - Creation of a cause-related diagram between the root cause and the problem. Root cause analysis methods 5 Whys. - Fairly a simple and well understood method. - Steps Define the problem. Keep asking "why?" to each answer. (“why?” to what happened) Until an end is reached where you need no other explanation - the root cause. - Not always 5 whys, may be more or less, depending on the situation. - Introduced by Sakichi Toyoda of Toyota Motor Corporation. - Criticised as a weak and too much simple tool (“Five Whys,” 2023). 5 Fishbone (Herringbone / Cause-and-effect / Ishikawa) diagram - A complex, but much descriptive method. - Structure Problem - the head of the fishbone. Major reasons and effects - splayed out as ribs. Root causes - subbranches of the ribs. - Reasons, causes, effects are grouped into categories wherever possible. - An overall picture is summarized. - Popularized by Kaoru Ishikawa based on concepts from early 20th century (“Ishikawa Diagram,” 2023). Fault tree analysis - Another descriptive, and logic-based method. - Adverse status of a system is checked. - A visual mapping of causative factors. - Uses graphical symbols. - Based on Boolean logic (“Fault Tree Analysis,” 2023). 6 Failure mode and effects analysis / Failure mode and effects critical analysis - Assess as many as possible ways of system failure. - Finally determine the potential failure mode (“Failure Mode and Effects Analysis,” 2023). Pareto chart. - A combination of bar chart and line chart. - Starting with most probable root causes at the left. - Named for an Italian economist (“Pareto Chart,” 2023). Scatter chart / scatter diagram / scatter plot. - Simple XY two dimensional graphs. - Analyse the relationship between two sets of data, the cause, and the effect. (How to Use 5 Common Root Cause Analysis Tools, 2023) Change analysis - Simple - Easy to understand and apply the corrective measures. - Explores for a divergence from a norm (A Guide to Root Cause Analysis - Examples, Tools, & More, 2023). 7 Analysis Analysis of the root cause of an adverse event occurred at a rural hospital, in Mannar district. Adverse event The demise of Mr. B Background of the incident People involved Three people of the same family Mr. B, a 56y old healthy male (ASA 1), neither previously examined for nor diagnosed with any comorbidities, a habitual alcohol consumer and a chain smoker, with a strong family history of hypertension (not revealed initially) Mrs. B, a 47y old female, - Mr. B’s Wife Mast. B, a 16y old male, - Mr. B’s Son Background of the Hospital Divisional hospital, with minimum facilities o Simple wound dressing could be done o Has a multipara monitor and a o ECG machine. One Medical officer and Two Nursing officers (for 24h) One functioning ambulance Nearest higher care facility - District General Hospital, Mannar o 25km away, ~20-30 min to reach. 8 Reason for the hospital visit Trauma to Mrs. B Injuries / Disabilities / Examination findings Mr. B No external injuries. Hyperventilating - anxiety / panic attack. Tachycardia. Complained of chest tightness. Stable vitals on room air. (Blood pressure appears not to be measured) Mrs. B A scalp laceration. Mast. B Few abrasions on the body - defence injuries. 9 Timeline (Details of the event in chronological order) Around 9.15am Trivial disagreement and misunderstanding, between Mr. & Mrs. B. Just before 9.30am Heated argument, between Mr. & Mrs. B. At 9.30am Mr. B assaults Mrs. B with a wooden pole. Impact on Mrs. B’s head and back. Mast. B arrives to help Mrs. B Argument between Mr. & Mast. B Mr. B slaps Mast. B Mast. B grabs wooden pole and hits Mr. B several times. o All three get injured. At 10.00am All three arrive together to the hospital Initial events at the hospital Medical officer examines all 3 and identifies the injuries. o ? blood pressure measured - Mr. B’s Medical officer instructs Mr. B to breathe in and out into a paper bag (do rebreathing). Nursing officers provide Mr. B, a paper bag. Medical officer sutures the scalp laceration of Mrs. B. Mr. B is provided low-flow oxygen - for reassurance. Finally, Mr. B stops hyperventilation, and feels ok. 10 At around 12.00pm Medical officer decides to transfer all three patients to District General Hospital Mannar Mrs. B and Mast. B refuses to go with Mr. B The medical officer decided to transfer Mrs. B and Mast. B in the ambulance. Mr. B is instructed to get himself admitted to DGH Mannar, immediately, on his own. The transfer form is handed to Mr. B. Mr. B decides to go home, as he was feeling fine. At 2.00pm Mr. B feels a sharp chest pain. Collapses in the room. At around 2.30pm Mr. B is taken to the same divisional hospital. Immediate resuscitation is started. Urgently transferred to the DGH Mannar. At around 2.50-3.00pm Mr. B is pronounced dead at DGH Mannar. Inquest ordered and a postmortem conducted. Cause of death - acute myocardial infarction Contributory factor - coronary artery atherosclerosis. 11 Root Cause Analysis Problem Mr. B died 1. Why? Acute myocardial infarction, with coronary artery atherosclerosis. 2. Why? Not diagnosed a. at the time of presentation. b. previously of any comorbidities. 3. a. Why - Not diagnosed - at the time of presentation? c. Not properly investigated. - for chest pain. No ECG taken / not monitored. BP not measured / not monitored. d. Missed the family history of hypertension. e. Tachycardia and chest tightness are attributed to anxiety / panic attack. f. The signs and symptoms and social history were not properly worked out. 4. c. Why - Not properly investigated? / e. Why - Symptoms and signs attributed to anxiety or panic attack? / f. Why - not properly worked out the situation? Misdiagnosis / negligence / lack of awareness / human errors of the medical team. 5. Why? Internal factors of the medical team. Lack of training and exposure. Lack of vigilance. Lack of staff members. Lack of support of expertise. 12 Habit of confining to a single diagnosis. / Not thinking about differential diagnoses. External factors of the medical team. Emotionally charged situation of the patients. 4. d. Why - Missed the family history of hypertension? f. History is not taken properly. g. Patient / family has not revealed the family history of hypertension earlier. 5. f. Why - History is not taken properly? Internal factors of medical team. Lack of skills / negligence / human error of the medical officer. External factors of the medical team. Emotionally charged situation of the three patients. 5. g. Why - Patient / family has not revealed the family history of hypertension earlier? Negligence / lack of awareness / emotionally charged situation of the patient and family. 3. b. Why - Not diagnosed - previously of any comorbidities? Negligence / lack of awareness of the patient and family. h. Patient has not been properly investigated for comorbidities. 4. h. Why - Not been properly investigated for comorbidities? Negligence / lack of awareness of the patient and family. Lack of access for the patients to routine checkups in the free health services. High expenses of the medical services provided by the private sector. 13 Q: Could this scenario be altered at any point, even if the proper diagnosis was not made at the rural hospital? A: Yes Q: How? A: It is not very clear, whether Mr. B had acute coronary syndrome or not, at the first time of presentation. Anyhow, he was referred to DGH Mannar for further treatment of whatever the diagnoses made. But he did not reach DGH Mannar in a viable condition. Why? Root Cause Analysis - 2 Problem Mr. B died 1. Why? Acute myocardial infarction, with coronary artery atherosclerosis. 2. Why? Though Mr. B was planned to be transferred to DGH Mannar, it did not execute properly. 3. Why? a. Patient was not transferred in the ambulance. b. Though he was instructed to get admitted to DGH Mannar by himself, he did not follow that order. 4. a. Why - Not transferred in the ambulance? c. Only one ambulance was available. d. Three of them did not like to go together in the same ambulance. e. Mrs. and Mast. B were sent in that only available ambulance, over Mr. B. 14 5. c. Why - Only one ambulance was available? Lack of infrastructure Most of the time, one ambulance seems to be enough to carry out the transfers, according to the usual patient flow pattern of rural hospitals. 5. d. Why - All three were not sent together? Internal factors of the medical team. Lack of proper decision making. Lack of vigilance. External factors of the medical team. Emotionally charged situation of the patients. 5. e. Why - Mr. B was not given the priority? Internal factors of medical team. Transferring two patients seem to have been more effective than transferring one patient. External factors of the medical team. Mr. B had no external injuries whereas other two had external injuries. Mr. B appeared to be fine after initial hyperventilating period. 4. b. Why - Didn’t Mr. B go to DGH Mannar? Because he was feeling fine. Negligence. Distance and travel time. Emotions - because his family was sent there too. 15 2. What measures would you immediately take to avoid such an adverse event? Measures to avoid adverse events Groups involved Medical team at rural hospital. Medical officers. Nursing officers. Medical administration team. Regional / Provincial Directors of Health Services. MO - planning/s. Medical teams from public health sector. MOHs. PHMs. Social workers. Medical team form local hospitals. Consultants - Physicians (VP), Surgeons (VS), Emergency physicians (EmP). 16 Immediate measures Staff education - by consultant EmPs/VPs. Staff training - by consultant EmPs/VPs. Implementing available protocols / guidelines. Immediately arranging a coverup / on-call service of the consultants available from the district general hospitals or the base hospitals nearby the rural hospital. Discussion Usually, the systems are made to ensure the safety and quality of the employees and clients. They are regularly updated, according to the present situation and necessities. Most of the time adverse events occur due to, - Known side effects. - Mistakes and faults. - Substandard of care. - Totally unexpected circumstances and events. Out of these, unexpected circumstances and known side effects are not preventable, but could be lessen. In contrast, the mistakes, faults and substandard of care are almost preventable. The immediate measures are necessary to halt the same, if not, a very similar adverse event being repeated immediately. Most of these measures (if not all) are focused on enhancing the prevailing system, simply because, Feasibility Adaptability Time taken to come into effect is very low. The identified flaws of the prevailing system should be addressed separately, to ensure the sustainability of a safe and quality system. 17 3. What are the long-term measures you will take to fix the system so that such adverse events will not occur?" Long term measures Provision of skills Prepare a schedule of regular training sessions to all the medical staff. Increase the frequency of the training sessions conducted. Mandating CPD (Continuous Professional Development) o Mandating ALS - live certificates, to all the medical officers. o Mandating at least BLS - live certificates, to all the nursing officers. o Mandating at least BLS certificate of regional level, to all the other health staff. Developing / Updating National guidelines. Developing Regional guidelines, based on the National guidelines. Implementing National / Regional guidelines. Developing / Enhancing “Emergency teams” in the District General Hospitals and above. Arranging a system of coverups / on-call services of the consultants / emergency teams, to the nearby rural hospitals. Increasing the number of healthcare workers in the units. 18 Provision of infrastructure Developing and implementing o a system of a continuous infrastructure upgrade. o a system of infrastructure maintenance and revision. Provide further facilities to the rural hospitals. / Upgrading. Discussion The clinical protocols, guidelines and standards are made to ensure a quality and safe environment of the patients (the clients) and the healthcare workers (the employees) (Heymann, 1994). The protocols are needed to be revised regularly to ensure the safety continuity of the safe and quality care, with the continuously updating knowledge and data and ever so versatile environment of the world. Hence the root cause analyses become an invaluable means of looking into the faults and pitfalls of the prevailing system and updating it regularly. Most of them focus on providing and updating the necessary skills, where as some focus on providing the infrastructure as listed above. 19 Reference A Guide to Root Cause Analysis—Examples, Tools, & More. (2023, September). Tulip. https://tulip.co/ebooks/root-cause-analysis/ Failure mode and effects analysis. (2023). In Wikipedia. https://en.wikipedia.org/w/index.php?title=Failure_mode_and_effects_analysis&oldid=11576 82358 Fault tree analysis. (2023). In Wikipedia. https://en.wikipedia.org/w/index.php?title=Fault_tree_analysis&oldid=1163025777 Five whys. (2023). In Wikipedia. https://en.wikipedia.org/w/index.php?title=Five_whys&oldid=1157076089 Heymann, T. (1994). Clinical Protocols Are Key to Quality Health Care Delivery. International Journal of Health Care Quality Assurance, 7(7), 14–17. https://doi.org/10.1108/09526869410074702 How to Use 5 Common Root Cause Analysis Tools. (2023, September). Tulip. https://tulip.co/blog/root-cause-analysis-tools/ Ishikawa diagram. (2023). In Wikipedia. https://en.wikipedia.org/w/index.php?title=Ishikawa_diagram&oldid=1173397606 Pareto chart. (2023). In Wikipedia. https://en.wikipedia.org/w/index.php?title=Pareto_chart&oldid=1138323332 Root cause analysis. (2023). In Wikipedia. https://en.wikipedia.org/w/index.php?title=Root_cause_analysis&oldid=1169029878 What Is Root Cause Analysis? - Definition from TechTarget.com. (2023, September). IT Operations. https://www.techtarget.com/searchitoperations/definition/root-cause-analysis
