Legal Incidents Reporting Requirements
Definition of Root Cause Analysis
The Agency for Healthcare Research and Quality defines the term root cause analysis as a structured method that is used to analyze adverse events (AHRQ, 2012). Wu et al (2008) point out that it was developed to explain the basic and causal factors that underlie organizations performance. Root care analysis used in health care is the process of scrutinizing serious occurrences that often border on fatalities made by various medical teams or a group of people who have sound expertise in this area (Flanders and Saint, 2005). It was originally designed for psychology and engineering but has expanded in application to other areas such as health care and administration. The analysis seeks to conduct a root cause analysis of medical failure to prevent future occurrence of the same (Wu et al, 2008). Root cause analysis is a reactive method meaning that it is used after the problem has occurred. It is intended to be a preemptive incident management strategy (Okes, 2009). It can also be used to forecast the occurrence of similar or related incidences in the future.
The problem of the case study is the wrongful administration of medicines dosage on a critically ill patient. For instance, a patient has received treatments for his disease. A medical employee has given a patient wrong dose of prescribed medicine. There were made changes in the drugs list that had been administered to a patient, therefore, misdoing of a medical employee harmed patients health condition. The problem was undetected for 16 hours, which aggravated the patients condition as a result of the overdose (Flanders and Saint, 2005). The mistake was not discovered even by the primary care givers in the hospital. A root cause analysis is necessary in this case study because it highlights things of medical negligence, poor coordination of the staff in the hospital, and lack of effective protocol in the supervision of critical patients and administration of drugs.
The problem should be investigated. Flanders and Saint (2005) mention that this is common, Clinicians who regularly care for hospitalized patients-particularly the ill, often observe medical mistakes. The problem also has the potential to lead to negative consequences on a patient involved. These incidences take place in the Intensive care unit of the hospital and patients here are especially prone to succumbing to the effects of such errors. The hospital administration can face legal consequences as a result of such incidences. Indeed, hospitals are required to report such incidences. The Minnesota Department of Health requires hospitals to report errors involving wrong dosage (Minnesota department of Health, n.d). The results of the investigations will enable the hospital to take measures to prevent the occurrences of such incidences and the resultant consequences.
Goals of Root Cause Analysis
The primary purpose of root cause analysis is to find elements that led to the variable characteristics of a particular incidence and its consequences. These variables include the nature, timing, location, and magnitude. These variables ensure that a problem is identified clearly. Often organizations make mistakes of assuming that the root cause analysis leads to the identification of one main problem. As seen in the case study, there were several problems that led to the particular event. The problems are largely independent and affect different parts of an organization. It is necessary to identify all problems and their magnitudes.
The second purpose is to formulate solutions for the found problems so as to eliminate or significantly reduce the occurrences of mistakes. These measures are presented as reports of the root cause analysis. These reports suggest modification or enhancement of processes that navigate the organizations business or specific processes (Andersen et al, 2009). It exploits structural nature of an organization through its analysis of weaknesses and strengths to formulate solutions for the root causes. These solutions in the short term solve the problem triggering the root cause analysis, validate and justify the process itself (Okes, 2009).
Limitation of Root Cause Analysis
The limitations faced in root cause analysis are caused by its inherent assumptions that are in its definition. Indeed, the term root makes the assumption that found problems have no internal complexities of their own. It also assumes that the problems are independent. These two assumptions are likely to emerge but are not common. Solutions that are implemented to eliminate the changes may end up exacerbating the problem. This creates a difficulty that results in causality webs (Okes, 2009). Causality webs often indicate the need for large scale changes in an organization. It is assumed that a few changes in an organization are enough to solve a problem. This may work in the short term, but the problem recurs when overlooked elements take effect.
Root cause analysis also leads to analysis of paralysis. This occurs when problems are difficult to solve in their nature. Usually an organization is unable to deal with the aspects that are able to be realized but difficult to acknowledge (Andersen et al, 2009). This is common in problems that result in conflict among those involved. Lastly, in health care, there is the controversial question on whether the risk of recurrence of the problem is reduced after the root cause analysis (Wu et al, 2008).
Steps in Conducting Root Cause Analysis
The first step is the identification of the analysis team to conduct the analysis. The team should consist of individuals who have the ability to contribute effectively to the analysis process. The team leader should be drawn from the quality management team of an organization from independent department where incidence has occurred (Flanders and Saint, 2005)
The team should identify and describe a problem. This involves identifying the attributes of a problem that may be quantitative or/and qualitative. This involved describing the aforementioned variables of magnitude, nature, and place.
Thirdly, the team should gather the relevant data and evidence and arrange it in chronological order to the occurrence of the incidence. The causes found should be divided into those that contribute to the sequential chain of events and root causes. Root causes are those that if removed would eliminate or disrupt the occurrence of the incident.
The team should formulate corrective actions that would eliminate or reduce the occurrence of the incident. If possible measures that mitigate the consequences of the incident can be mentioned.
The recommended solutions are then implemented. The root cause analysis program should also be measured for success. Failure for this measurement results in the whole process being a trial and error. To measure this success, various things can be assessed. They include the ratio of the analysis conducted and incidences that trigger analysis, amount of time spent reacting to incidences, frequency and severity of the incidences before and after analysis.