A systematic analysis of an event or near-miss within the healthcare setting is known as root cause analysis (RCA). The Root Cause Analysis is the most commonly used method for determining the underlying causes of a medical error. An efficient Root Cause Analysis, on the other hand, goes beyond the immediate result to determine the contributing factors or chain of events that led to the error. It analyzes errors using a process-focused and organized framework to ascertain what happened, what caused the error, and what steps should be taken to prevent the error from happening again. RCA avoids the tendency of assigning individual blame by looking at both latent and active errors.
Area of Improvement
When medical errors occur, the natural reaction may be to determine which employees were involved and to terminate their employment. The assumption is the employees did something wrong. Though that may be the case, there is no guarantee that the same incident will not occur again, with other employees involved, unless the healthcare facility digs deeper to understand exactly what happened, why it happened, and what needs to change to prevent future mistakes.
Diagrams of The Clinical or Workflow Process
Physical Assessment Clinical Workflow Process
Therapy Process Workflow
A Fishbone Diagram of Constraints
The Steps for Improvement, Utilizing the Five-Whys Tool
The proposed framework for RCA and action plan initiated in response to patient falls is aimed at addressing the following questions: 1. Why? 2. What else? There were eight steps for improvement based on the RCA. The first step was defining the problem, followed by collecting data. The third step will involve determining the factors that led to the problem using the five whys tool. The fourth step will be determining the root-causes, and this will be succeeded by identifying the corrective actions. The sixth step will be finding out the solutions to avoid recurrence of the problem. The seventh and last steps will be implementing the solution and determining the applicability of the solution in other problems respectively.
Suggested Changes for Making the Improvement
For improvement in the patient safety, avoiding patient falls, several improvement measures are recommended for adoption. The first measure involves posting at every treatment unit notices regarding patient safety. This is aimed at encouraging the patients to actively inform the medical personnel if they need oxygen equipment or have any special illness, to reinforce health education especially when the patients are receiving the rehabilitation treatment, and to inform the patient for contraindications for electrotherapy. Secondly, psychiatrists should regularly carry out detailed assessments of fall risk factors in patients as an initial step of preventing patient falls. The receptionists should provide the patients with safety notices when they are arranging their schedule of treatment.