Accreditation Audit (AFT2) Task 2
Executive Summary: Root Cause Analysis

Accreditation Audit (AFT2) Task 2
Executive Summary: Root Cause Analysis
A. Aspects of Root Cause Analysis
1. Description of Sentinel Event Nightingale Community Hospital is conducting a root cause analysis of a pediatric abduction which occurred during a post-operative discharge process. “A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. Such events are called "sentinel" because they signal the need for immediate investigation and response.” (The Joint Commission, n.d.) In this event, a three year old child was admitted to Nightingale Community Hospital for a bilateral myringotomy. The mother of the child stepped out during the surgery in order to run an errand involving her other child. The mother was told the surgery would take about 45 minutes. The mother relayed that she should be back after the surgery to pick up her child. The mother did not respond after the recovery, even though the recovery nurse called out to the waiting area and paged for the mother. The patient was then transferred to the discharge nurse. The child was agitated waiting for her mother to return. Coincidentally, the father was at the desk and the nurse invited him to see his child. The nurse was relieved as the child changed her affect to one of excitement and called him daddy. After waiting thirty minutes the father offered to take his daughter home. The nurse agreed and provided the discharge paperwork to the father. The child abduction was reported two hours after the patient’s discharge, upon the mother’s return. This was due to the fact that the patient was released to the father but the mother had sole custody of the child; unbeknownst to the discharge nurse. The police responded as per policy calling a Code Pink and notifying local law enforcement. The child was found at the father’s domicile 30 minutes after the mother arrived at the hospital. The hospital CEO apologized to the mother and assured her they would look into the event and change procedures to thwart the recurrence of this type of event.
2. Roles and Responsibilities
According to the interviews, the patient presented with her mother to the registrar. The registrar’s primary functions are to collect patient identification, demographic and insurance data. Additionally, the registrar ensures the consent for admission and payment are signed and filed accordingly. The registrar, in her interview, explained her duties and stated she followed the process as she was trained.
The pre-operative nurse received the patient and completed the pre-operative nursing assessment by completing a standardized form. She obtained a hospital gown for the patient, initiated an intravenous infusion, administered the patient’s pre-operative medications, documented in the patient records, ensured the parent signed the consent forms for the bilateral myringotomy procedure. The nurse also noted the mother’s name and cell phone number on her noted pad because the mother expressed she had and errand to run involving her seven year old son and that she would return after the surgery to pick up her daughter. She then handed the patient off to the operating room nurse.
The operating room nurse’s responsibility is to continually “assess, diagnose, plan, intervene, and evaluate their patients” throughout the operative procedure until the hand off to the recovery nurse. During the interview, the operating nurse had nothing factual to add about the incident but gave her opinions about potentially precipitating factors which will be address later in this paper.
The recovery nurse is especially attuned to the side effects of anesthesia and understands how to assess and treat in order to mitigate the side effects of anesthesia to allow for a good recovery from an operative procedure. In this case the recovery nurse said he took report from the operating room nurse then called out and paged the patient’s mother as the girl was waking up. He said the mother never responded. He stated he recovered the patient until he had to hand off to the discharge nurse.
The discharge nurse performs a nursing assessment and executes doctor’s orders to ensure the patient is ready to be discharged to home. This nurse is responsible for ensuring all the necessary paperwork is in order, the patient or guardian understand the discharge instructions, and that there is an handoff between the staff and the parent. In the interview she recounted that the child was excited to see her dad and called him “dad” and did not think about a potential custodial issue. Since the mother had not responded to her page after half an hour and the father offered to take the child “home,” the nurse agreed and provided the discharge instructions.
Other than performing the surgical procedure, the surgeon’s responsibility is to ensure the hospital appropriately prepares for his patient. This would include providing doctor’s notes and orders and communicating with the team of any anomalous points regarding the patient’s care. The surgeon did not offer much in his interview other than his opinions.
The police are responsible for various duties in regards to staff and patient safety and security. The police execute exercises in order to test security policies and ensure the personnel are able to respond appropriately with each of the high risk scenarios dictated by law and policy. They advise of potential risk factors and recommend possible solutions to the executive staff. Additionally, the police are the hospital liaison between local emergency services and the hospital. They also should work collaboratively with the staff in order to achieve awareness and compliance. In this case the officer responded quickly once the child abduction was reported.
The Chief Nurse Executive, although not directly involved in this event, is responsible for the overall practice of nursing and nursing education within the hospital system. Additionally, this individual is responsible for breaking down the barriers in communication among the nursing staff.
3. Barriers to Effective Interaction There are several barriers to effective interaction in a healthcare setting. Professional or job dissatisfaction plays a role in poor communication because, in this state of mind, a person performs at a minimal level. “When someone is unhappy, they don't focus well and they don't pay attention to their tasks.” (McFarlin, n.d.) As such, they may not seek to go that extra step to ensure everything is addressed for each individual patient. Another barrier can be job stress. If an individual feels overwhelmed by the amount of work they have to do and they feel they that everything hinges on their actions, it becomes stressful. This stress may create the potential for critical steps to be overlooked or a minor step which coupled with other missteps creates a sentinel event. Education is another barrier to effective interaction. This works downward and upward. Some professionals believe they are above needing to explain anything unless they are asked. It seems it is their right to have that information due to their education. On the other hand, other employees feel intimidated by the education others have had and are intimidated by their own lack of education and will not ask necessary question. This creates a communication impasse that may result in a negative patient outcome. Lastly, organizational culture may be a crucial barrier to effective interactions. If a culture places greater value on individual performance rather than teamwork, then, from a cultural perspective, collaboration will be undervalued. The organization must endeavor to provide the means, training, space, and time for teams to work in a collaborative manner. This philosophy will foster communication regardless of education and develop greater job satisfaction for the team. It will also allow for team members to feel comfortable calling a “time out” when something is awry or asking for help when they are overwhelmed. In this event there are some of these elements present. The pre-operative nurse continually alluded to the fact that she does everything. This can be indicative of stress and may be a contributing factor for why she did not pass on the mother’s phone number to the OR nurse. In the case of the registrar, education may have been a factor. She stated how she only followed the process as she was trained. This also may be a job satisfaction issue as she only accomplished her job to the limits set. Lastly, the organization needs to allow for a team huddle before cases in order to ensure they have covered all essential information. Such team collaboration may allow members, who otherwise not mention anything, to speak up.
4. Quality Improvement Tool
The quality improvement tool to be utilized for this root cause analysis will be the Ishikawa Diagram or fishbone diagram. Additionally, the team will use process flowcharting to visualize the process. The fishbone diagram allows a team to brainstorm causative factors leading to a certain incident. In a hospital setting, we usually use the 4 Ps: Policy, Procedure, Plant, and People. As the team brainstorms the causes, each cause is added to one of these bones (the 4 Ps) along the spine. For each of these causes, the team must ask why each cause existed. This will aid in arriving at the root cause or causes. (Figure 1) (Introduction to Continuous Quality, 2007) Process flowcharting is an important tool in root cause analysis as it allows all involved in the process to visualize how they affect and are affected by other pieces of the process. Most people understand the parts of a process before and after the part they own, but seldom understand the entire process. Flowcharting allows the team to see the process in a multidisciplinary fashion and opens the floor for discussion and improvement.

Figure 1. Sample Fishbone Diagram

B. Corrective Action Plan
1. Issue: Need to identify a minor’s legal guardian to deter potential abductions. i. Actions: a. Adjust policy to require identical banding for minor and legal guardian(s). (Sentinel Event, 1999) b. Adjust policy to require all patient notations to be made in the electronic health record. c. Adjust policy to require identification band check prior to discharge. d. Adjust policy to mandate doctor’s notes in order to secure operating room time. e. Adjust nursing assessment tool in pre-op to include psychosocial assessment. f. Determine all locations where pediatric patients are at risk for abductions. g. Implement abduction alarms at all abduction risk areas. (Sentinel Event, 1999) h. Implement SBAR in all handoffs. ii. Implementation Timelines a. Policy adjustments must be immediate. 1) Resources required: administrative changes to policy; CEO concurrence; dissemination via email, staff meetings, and postings. b. Training on policy adjustments must be immediate after policy adjustment. 1) Resources required: time during staff meetings, CNE involvement, documentation of training in training record c. Nursing tool adjustment must be immediate. 1) Resources required: administrative changes to form; CNE involvement in training; documentation of training in training record. d. Convene department chiefs to determine at risk areas within 14 days. 1) Resources required: Meeting time and place; CEO support; scribe for meeting minutes. e. Purchase and install alarm systems in at risk areas within 30 days of department chief meeting. 1) Resources required: logistics requisition; allocation of funds for purchase, installation and training; time for training personnel. f. Provide training on system to the sections requiring the alarm system within seven days of installation. 1) Resources required: time for training; CNE involvement in training; documentation of training in training record. g. Provide SBAR training for all areas requiring patient handoffs. (SBAR, n.d.) 1) Resources required: time for training; CNE involvement in training; documentation of training in training record. iii. Monitoring a. Execute assessment drills quarterly for the first year to ensure personnel understand their responsibilities during child abduction scenarios. b. Continue quarterly assessment until there is 100% compliance in consecutive quarters, then monitor semi-annually. iv. Benchmark a. Only 100% compliance and understanding of policy will be considered acceptable performance in this area.

References
Cause and Effect Analysis: Identifying the Likely Causes of Problems. (n.d.). Cause and Effect
Analysis (Fishbone Diagrams). Retrieved July 26, 2014, from http://www.mindtools.com/pages/article/newTMC_03.htm Introduction to Continuous Quality Improvement Techniques for Healthcare Process
Improvement . (n.d.). Statit Quality Control First Aid Kit. Retrieved July 28, 2014, from http://www.statit.com/services/CQIOverview.pdf McFarlin, K. (n.d.). The Effects of Low Job Satisfaction. Small Business. Retrieved July 28,
2014, from http://smallbusiness.chron.com/effects-low-job-satisfaction-10721.html
SBAR Technique for Communication: A Situational Briefing Model. (n.d.). SBAR Technique for
Communication: A Situational Briefing Model. Retrieved July 28, 2014, from http://www.ihi.org/resources/Pages/Tools/SBARTechniqueforCommunicationASituation alBriefingModel.aspx
Sentinel Event Alert. (1999, April 9). The Joint Commission, Issue 9, 2. Retrieved July 28, 2014, from http://www.jointcommission.org/assets/1/18/SEA_9.pdf
The Joint Commission. (n.d.). Sentinel Event. Retrieved July 2, 2014, from
http://www.jointcommission.org/sentinel_event.aspx