Root Cause Analysis

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Root Cause Analysis
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Root Cause Analysis

• Definition
• process for identifying the basic or
  contributing factors that underlie variations in
  outcomes
• Used to examine adverse events
• Definition adverse events are unwanted things
  happening as used here, often they happen over
  and over again
• Used to examine close calls
• Used to identify trends to prevent further
  occurrences

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Root Cause Analysis

• Most problems do not have an obvious solution -
  that is why they remain problems
• Or, you may not have realized that a problem even
  exists
• Example, what should your facilitys rate of
  restraint use be?
• What about pressure ulcers?
• These dont mean that the facility isnt doing a
  good job, just that it could do better!
• Real objective is to improve the process at the
  fastest possible rate
• Root Cause Analysis leads to suggestions for
  improvement

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Root Cause Analysis

• Errors usually result from faulty design of
  process, not worker negligence
• Poor design puts staff in situations where errors
  are likely to occur
• Example No sink in room or hand sanitizers
  (missed hand washing)
• Example No cleanser near bathroom (stinky rooms)
• Root cause analysis provides a path to figure out
  how to correct problems and prevent further
  occurrences
• Assigning blame does not prevent reoccurrence

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Root Cause Analysis

• Need to ask Why? Why? Why?
• Identify underlying functions leading to poor
  outcome
• Determine main or most important cause and all
  the contributing factors you can think of
• Usually begins by measuring components or pieces
  of process
• Think about each step in the process, and how it
  can be measured

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Root Cause Analysis Techniques

• Organize a team with representation from a
  variety of departments
• Who will be included in
• Brainstorming
• Identify barriers to favorable outcome
• Collect data and sort to identify common threads
  or trends
• Use fishbone

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Root Cause Analysis
The next step is for the team to brainstorm on
possible causes Six categories. 1.
Communication 2. Training 3.
Staff Fatigue/Scheduling 4. Environment
and Equipment 5. Rules/policies/Procedures
6. BarriersFor each category the team
needs to decide if it was a factor in the event
being reviewed.
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Root Cause AnalysisRules of Causation

• Causal statements must clearly show cause and
  effect relationships
• Reader needs to understand and follow your logic
  in links (cause -effect conclusions)
• Negative descriptors such as poorly or
  inadequate are not used in causal statements
• Broad, negative words do not describe actual
  conditions
• Each human error must have a preceding cause
• Must investigate why the error occurred

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Root Cause AnalysisRules of Causation

• Each procedural deviation must have a preceding
  cause
• Example why are steps to a procedure missed by
  the nurse?
• (example Why is a daily pain assessment not
  performed?)
• Failure to act is only causal when there was a
  pre-existing duty to act
• Duty may be assigned through regulation or
  standards of practice

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Root Cause Analysis1. Communication
The area of communications include questions such
as Was the resident correctly identified?
Was existing documentation of treatment plans
clear?
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Root Cause Analysis2. Training

• Training includes questions such as
• Was training provided prior to the start of the
  process?
• Were the results of the training monitored over
  time?

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Root Cause Analysis 3. Staff Fatigue/Scheduling

• Questions in this section may include
• Did scheduling allow personnel adequate sleep
• Was the environment free of distractions?
• Was fatigue properly anticipated?

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Root Cause Analysis4. Environment and Equipment

• Some questions for this area are
• Had there been an environmental risk assessment
  of the area?
• Was there a maintenance program in place to
  maintain the equipment involved?

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Root Cause Analysis 5. Rules/Policies/Procedures

• Some sample questions for this area include
• Were there written up-to-date policies and
  procedures that addressed the work processes
  related to the event?
• Were relevant policies/procedures clear,
  understandable, and readily available to all
  staff?

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Root Cause Analysis6. Barriers

• This area includes questions such as
• What barriers were involved in this event?
• Would the event have been prevented if the
  existing barriers had functioned correctly?

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Root Cause AnalysisStatements

• Root Causes explain the teams findings about
  what must be fixed
• Root Causes guide everything else that follows
• (task assignment, actions, outcome measures)
• Strong Root Causes set up success

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Root Cause AnalysisStatement

• The first step is writing a Root Cause Statement
  is to pick the contributing factor that the team
  feels is the strongest. The root cause statement
  is written according to five simple rulesFIVE
  RULES
• Show Cause and effect
• Nothing negative about people
• Fix systems, not people
• Fix norms, not people
• Duty to act

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Root Cause Analysis Cause and Effect

• WRONG
• A nurse was fatigued
• RIGHT
• With overtime, nurses are often scheduled more
  than 40 hours a week as a result, fatigued
  nurses are more likely to misread instructions

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Root Cause Analysis Rule 2. Nothing negative
about people

• WRONG
• Poorly written procedure
• RIGHT
• The restraint procedure has 8 point font and no
  illustrations so staff dont use it, increasing
  the likelihood that restraints are applied
  incorrectly.

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Root Cause Analysis Rule 3. Fix systems not
people

• WRONG
• Staff did not notice the resident was missing
  for at least 8 hours
• RIGHT
• Due to a malfunction in the door/vest wandering
  alarm, a resident was able to elope undetected

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Root Cause Analysis Rule 4. Fix norms not
people

• WRONG
• Staff are waking patients at night
• RIGHT
• Bathing policies and prn med passes need to be
  adjusted to respect resident sleeping preferences

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Root Cause Analysis Rule 5. Duty to act

• WRONG
• The nurse did not check for STAT orders
• RIGHT
• The absence of an assignment for nurses to check
  for STAT orders increased the likelihood that
  STAT orders would be missed or delayed

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Root Cause Analysis Where do teams get stuck?

• Lack of information (e.g., few interviews, few
  references, limited or no simulation, limited
  time, etc.)
• Focus on too narrow a problem (saving one
  particular patient)
• Focus on too big a problem (saving the world)

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Root Cause Analysis How to get teams un-stuck

• Do more interviews
• Check the literature
• Check with professional colleagues (contact
  similar facilities in different parts of the
  country)
• SIMULATE the event
• Do some more brainstorming
• Find the time to do the best job possible
• Engage the medical director

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Root Cause Analysis How to get teams un-stuck

• Stick to/focus on the situation at hand
• Focus on what can be done to help other
  residents, families or staff in the future
• Select bite-sized actions/outcome measures for
  events that you know occur frequently
• look for volunteers, use short cycles of change,
  fix one thing at a time

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Root Cause Analysis Action

• Set reasonable/attainable goals
• Link goals to measurement
• Choose an action that fits the root cause
• Avoid outcomes like training, writing a
  policy, pay more attention
• Instead pick a stronger approach such as
  standardize, checklist, Equipment fix,
  Timeline for multiple actions
• Make changes that have the highest potential
  impact facility-wide but test changes in one area
  first
• Assign who, as well as when

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Root Cause Analysis Resident Reports Pain

• While passing her in the hallway a new Certified
  Nursing Assistant told the Charge Nurse that a
  resident was complaining of pain. During
  orientation the CNA was told to always inform the
  Charge Nurse of resident changes that could
  indicate pain. The Charge Nurse is an agency
  nurse who is currently working a double and
  replied to the CNA, She just wants attention. I
  dont think she is really in pain. and kept
  walking down the hall.

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Root Cause Analysis Resident Reports Pain

• Was communication from the CNA adequate?
• Was the CNA oriented to the pain management
  program?
• Was the Charge Nurse following the policy and
  procedure and standards of care?
• Reason?

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FISHBONE DIAGRAM GROUPINGS
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Root Cause AnalysisFishbone Diagram People

• Lets look at the nurse and CNA
• Fatigue (short staffing, personal problems)
• Communication (lack of information regarding the
  process)
• Training (lack of orientation or ongoing
  training, lack of competency checks)
• Lack of supervision
• Other

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Root Cause AnalysisFishbone Diagram Policies
Procedures

• Procedures/ Rules/Policies
• No written policy and procedure
• Failure to follow the policy/procedure
• Standards of practice not known
• Standards of practice not followed
• Lack of supervision to assure process is followed
• Lack of orientation or information regarding the
  process and/or resident needs
• Other

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Root Cause AnalysisFishbone Environment
Equipment

• Using the fishbone diagram
• Equipment/Environment (examples)
• Medication for pain hard to obtain - locked away
  from medication cart
• Furniture not comfortable resulting in
  exacerbation of pain
• Improper restraint leading to immobility and pain
• Inadequate supplies for positioning
• Assistive equipment not fitted for resident,
  causing pain

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The PDSA Cycle for Learning and Improvement
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Root Cause Analysis Tips (continued)

• Participation of leadership of the organization
  is important
• Participation of individuals most closely
  involved is necessary
• Cannot be contradictory
• Doesnt leave obvious questions unanswered

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Root Cause Analysis Summary

• Look at all information.
• Investigate thoroughly
• Use the Fishbone Diagram
• Propose many solutions.
• Look at the process
• Pick one intervention for testing in a small area
  
• (PDSA)

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76 yo with burns

• Harry Owens, a former a landscaper, is 76 yo
  widower and resident at Rolling Meadows NH, has
  Alzheimers. He helps with the flowerboxes on the
  unit. Harry has two sons and a daughter. The
  boys live out of state and his daughter
  Catherine visits after work.
• Harry is oriented to self and recognizes familiar
  faces. Although, Harry uses a w/c to wheel
  himself throughout the unit, he is often found in
  the kitchen snacking or rummaging through
  closets. He has a snap-on belt on his wheelchair,
  which he can not self release for safety and
  positioning. He c/o about the belt every time it
  is put into place. He attempts to get out of the
  wheelchair to ambulate on his own if hes not
  belted in. Last wk the housekeeper found Harry
  twice rummaging through other residents personal
  closets and personal belongings.
• He was found by the housekeeper lying on the
  floor in another residents room with burns to
  his chest and arms. A partially burned snap-on
  belt was attached to his wheelchair. He was last
  seen in front of the nurses station waving to a
  CNA who was returning from her break to have a
  cigarette.
• He was sent to the hospital where they diagnosed
  Harry as having 3rd degree burns to his chest and
  arms.

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With your team consider the following questions

• When during the day is the person at risk?
• What is the best treatment and what are your
  strategies for accomplishing it?
• What are the potential barriers to that
  treatment?
• What conflicts are there between treatment
  protocols and the individuals patterns or
  rhythms?
• How can these conflicts be reconciled to achieve
  the best outcomes
• What conflicts exist between the treatment
  protocols and the institutional pressures (i.e.
  Schedules, other departments needs)
• How can you reconcile these to support your care?
• Look at the HATCh model. In each of the domains
  what is needed to care for this individual?

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HATCh Holistic Approach to Transformational
Change
Environment
Care practices
Workplace practices
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The analysis (1/3)
Were flower boxes easily accessible?
Where activities scheduled at this time?
Resident on independently wheeling self on unit
Resident is a fall risk according to fall
assessment
Snap-on belt used to maintain position in
wheelchair?
Snap-on belt used to maintain position in
wheelchair?
Did staff receive training for the restraint and
facility protocols?
Are other restraint alternatives available?
Resident complains about the snap-on belt
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Analysis (2/3)
CNA left cigarette lighter at the nurses station
How was the ignition source obtained?
Why was this restraint device used?
What was the ignition source?
Resident falls out of his wheelchair
Resident is wearing a snap-on belt
Snap-on belt ignites and breaks
Staff member called in sick
Was a reduction ever put into place?
Was the resident a known fire risk?
Why is snap-on belt combustible?
Short staffed. When returning from break CNA was
called to assist co-worker
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Analysis (3/3)
Resident not seen for 15 minutes
Short staffed. When returning from break CNA was
called to assist co-worker
Resident used lighter that CNA left at nurses
station
Snap-on belt breaks and resident slips out
Resident found burnt, lying on the floor
Resident treated and transferred to the local
burn unit
Staff member called in sick
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Esther 77 yo post hip pinning

• EXERCISE Esther is a 77-year-old widowed F,
  living independently at home. Her daughter lives
  close by and visits frequently. 6 d ago, Esther
  Fx R hip from a fall at home. At the hospital,
  hip was pinned. Since her admission to the SNF
  2d ago, she c/o significant postop pain for which
  she has a prn pain medication scheduled. PT and
  OT were ordered but Esther refused therapy
  stating, she was not ready to move too much.
  The therapy director has mentioned to the DON
  that her physician should be called because it is
  getting difficult to justify Medicare coverage.
  She stays perfectly still for long periods of
  time with her eyes closed. Her preferred
  position is supine with the head of the bed
  elevated and a pillow under the affected right
  leg. She rings the call light frequently for the
  bedpan and for pain medication. She is eating
  small amounts of a soft diet.

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With your team consider the following questions

• When during the day is the person at risk?
• What is the best treatment and what are your
  strategies for accomplishing it?
• What are the potential barriers to that
  treatment?
• What conflicts are there between treatment
  protocols and the individuals patterns or
  rhythms?
• How can these conflicts be reconciled to achieve
  the best outcomes
• What conflicts exist between the treatment
  protocols and the institutional pressures (i.e.
  Schedules, other departments needs)
• How can you reconcile these to support your care?
• Look at the HATCh model. In each of the domains
  what is needed to care for this individual?

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95 yo with pressure sore

• Aunt Sharlie is 95 yo with a h/o CAD, DM and
  severe PVD. She weighs 98 lbs, is 50 tall and
  has dementia. Aunt Sharlie scoots around the
  facility in her wheelchair using her L foot to
  propel herself. She can stand and take a few
  steps.
• When staff attempt to reposition her she refuses
  and says Leave me alone, will ya? She eats
  small amounts of finger foods, spits out most of
  her pills, and is hard to slow down because of
  her activity level. Prior to her residence at the
  nursing home she was an avid gardener and enjoyed
  walks in the park.
• She developed a pressure ulcer on the right heel
  last summer, which resulted in an above-the-knee
  amputation in November. During this time she also
  developed a stage III pressure ulcer measuring
  4x3x2 at the coccyx. The pressure ulcer has
  healed, but she is still at high risk. A Foley
  catheter is being used to manage incontinence and
  keep the coccyx dry.

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With your team consider the following questions

• When during the day is the person at risk?
• What is the best treatment and what are your
  strategies for accomplishing it?
• What are the potential barriers to that
  treatment?
• What conflicts are there between treatment
  protocols and the individuals patterns or
  rhythms?
• How can these conflicts be reconciled to achieve
  the best outcomes
• What conflicts exist between the treatment
  protocols and the institutional pressures (i.e.
  Schedules, other departments needs)
• How can you reconcile these to support your care?
• Look at the HATCh model. In each of the domains
  what is needed to care for this individual?

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88yo F with Adverse drug event

• An 88 yo F with dementia, a HTN, and CAD s/p CABG
  went from NH to ED for worsening confusion. She
  had been in hospital 6 wks ago for urosepsis, and
  allergy to levofloxacin was noted.
• Initial evaluation revealed leukocytosis and
  pyuria, but no fever or flank pain. The ED MD
  concluded that a UTI was the most likely cause of
  the altered mental status, and prescribed
  levofloxacin.
• The first dose was given on the medical floor
  shortly after the patient arrived.
• Over the next 6h, patient became increasingly
  agitated and required sedation and restraint. She
  developed a diffuse erythematous rash across the
  chest and back, swollen lips and tongue, and
  audible wheezes ? anaphylactic reaction! In the
  ICU she was treated with IV steroids,
  antihistamine, and inhaled beta agonists. The
  levofloxacin was changed to an intravenous
  cephalosporin.
• After the event, the patients paper chart was
  brought to the ICU from the Medical Records
  Department. The D/C summary from last admission
  reported an allergic reaction to levofloxacin.
  Her daughter, arriving later that evening, was
  exasperated to learn of her mothers condition.
  She said, Youre supposed to help her get
  better, not worse!

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Questions

• Should the nursing home physician confer with the
  Emergency Department physician at the time of ED
  evaluation?
• Should a demented patient wear a medical alert
  wristband?
• Is there a trade-off between clinicians attempts
  to provide timely care such as rapid
  administration of antibiotics and other
  treatments and safety?

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Interviews

• The Emergency Department Physician
• I saw the patient and requested her records. I
  thought about treating her UTI with a
  cephalosporin, but the nurse told me the patient
  had very thin veins and tenuous IV access. I
  thought a quinolone made sense because you can
  take it orally. I reviewed the transfer sheets
  from the nursing home record and saw no note of
  an allergy. Unfortunately the patient was too
  sick to tell me about her allergies. I wish Id
  waited for the chart to come up from Medical
  Records, but there was a trauma case coming in
  and we needed the bed.
• The floor nurse
• It was a busy day. We had 4 admissions all at
  once. I settled the pt and went on to help the
  other nurses. I administered all my pts meds,
  but I didnt get a chance to sit down and do my
  paperwork until the end of the shift. I then
  remembered hearing about the pts last admission
  and recalled there was an allergy to
  levofloxacin. But by then, she was already
  wheezing and swollen. We all rely on the doctors
  and pharmacists too much to get the order right.

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Interviews

• The pharmacist
• What a catastrophe! I remember receiving the
  order for levofloxacin. The pharmacy computer
  showed that the patient had no known drug
  allergies. We dispensed the drug and sent it up
  to the floor. Although the pharmacy computer
  keeps a record of every drug allergy that is
  brought to our attention, there is no consistent
  way that the information gets to us. If it is
  written in an admission note or discharge summary
  but not on the physician order sheet, there is no
  way we would learn of the allergy. We do the best
  we can, but we need some help from the
  clinicians.
• The daughter
• I am beyond exasperated. I know that things are
  busy and that the doctors and nurses here try to
  do the right thing, but they ought to know better
  than to give my mother a medicine shes allergic
  to. If you cant get a simple thing like that
  right, how can patients expect that youll get it
  right when you do something complicated? Whats
  so hard about saving allergy information in a
  single place so everyone can find it? I know all
  about my mothers allergies and medications. Why
  couldnt somebody give me a call?

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80 yo M with pressure sore

• Charlie is an 80-year-old retired police officer,
  admitted to Happy Hills NH a few months ago with
  L hip fx, NIDDM, dementia, and peripheral
  neuropathy. He is 5, 9 and weighs 146 lbs, alert
  and pleasantly confused. Ambulation is poor. He
  sits in a straight back chair most of the day.
  Occ. he wanders on the unit looking for his
  patrol car and top-secret documents (an elopement
  risk!). Upon admission the nursing staff
  immediately initiated a plan of care to prevent
  the development of a pressure ulcer, including
  placement of an air mattress on his bed and a
  cushion in his chair. He has a sacral Stage II,
  although its improved some, and measured at 6 x
  5cmx0.5 this morning. Staff has been asked to
  place him in bed for an hour in the late morning
  and then again late afternoon to relieve
  pressure. He is continent of urine on occasion
  and staff state His brief is always heavily
  soaked with urine when we change him q 2h
• Last week Charlie became more confused and his
  food intake lessened. Staff noticed a blister on
  his L heel, possibly caused by his poor fitting
  shoes when he does wander in the hall in pursuit
  of crooks.The nurse promptly notified the
  residents daughter and MD of the blister, as
  well and the residents overall health decline.
  MD ordered dietary supplements, a foam foot
  elevator while in bed, and an Rx for the blister.
  He continued to lose weight, and blood sugars are
  now unstable, and his L heel blister worsened to
  the where the nurses described it in their
  documentation as a stage II PU draining large
  amounts of foul smelling exudate.

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With your team consider the following questions

• When during the day is the person at risk?
• What is the best treatment and what are your
  strategies for accomplishing it?
• What are the potential barriers to that
  treatment?
• What conflicts are there between treatment
  protocols and the individuals patterns or
  rhythms?
• How can these conflicts be reconciled to achieve
  the best outcomes
• What conflicts exist between the treatment
  protocols and the institutional pressures (i.e.
  Schedules, other departments needs)
• How can you reconcile these to support your care?
• Look at the HATCh model. In each of the domains
  what is needed to care for this individual?

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• Stefan Gravenstein, MD, MPH, CMD
• Clinical Director
• 401-528-3200
• sgravenstein_at_qualitypartnersri.org