Type: Analysis
Pages: 3 | Words: 666
Reading Time: 3 Minutes

Root Cause Analysis is a planned method used to study grave adverse issues. Initially originated to analyze industrial accidents, Root Cause Analysis is now widely developedas a fault analysis tool in healthcare. The main function of Root Cause Analysis is to identify underlying problems that enhance the possibility of errors while evading the trap of focusing upon faults by individuals. Therefore, the objective of Root Cause Analysis is to identify both latent and active errors.

Generally, Root Cause Analysis follows a pre-specified procedurethat begins with collection of data and event reconstruction through record re-evaluation and participant interview. A multidisciplinary team then analyses the sequence of actions leading to the mistake, with the purpose of identifying how the event took place and why it occurred. The ultimate goal of Root Cause Analysis is to prevent potential harm by doing away with latent errors that regularly underlie adverse incidents (American ACMQ, 2010). This paper is going to use Unintended Retention of Foreign Object Scenario as an example of how Root Cause Analysis can be applied to an event.

The first step of the Root Cause Analysis is to identify the problem through asking; what the problem is, when it happened, where it happened, and how it affects the goals. By asking, “˜when’, a proactive Root Cause Analysis, rather than a specific incident, is being discussed. What this means is that an analysis of how the issue could have happened, rather than what really did happen because of a specific incident is being done. As for the “˜where’ question, there are two parts involved (Galt & Paschal, 2010). Firstly, it is specifically asking about physical location where the fault occurred. Here, it is within the body of the patient. Secondly, what task was being carried out when the problem happened? The problem being discussing here is an outcome of surgery (Walshe & Shortel, 2012).

Next, the problem in context with the goals of the organization is defined. If the issue affects an organizational objective, then the impact is captured on the outline. The patient’s safety goal is affected because there is a possibility for serious injury or even death from leaving the foreign object within the body of the patient (Hitchings, Davies-Hathen, Capuano, Morgan, & Bendekovits, 2008). The compliance and organizational goals will also be affected since that event should have never occurred in the first place. In addition, the patient’s service goal is affected because the retention of the foreign object is looked at as a hospital-acquired condition. Finally yet importantly, the average costs incurred because of the retention of the foreign object is a lot (Heuvel, 2008).

The second step is to identify the causes. In this step, the occurrence is broken down into root causes, which are then captured on the Cause Map. The Map starts by noting the goals that were impacted as identified in the problem outline. The following is a simplified version of mind map to illustrate how the identification of the causes is done (Heuvel, 2008).

The final step taken is the selection of the best resolutions to reduce the risk at hand. Once the Cause Map has been built to a satisfactory level of details with supporting evidences, the results step can be commenced. The Cause Map is useful in the identification of each possible solution to given issue in order that the best solutions can be chosen. It is easier to key out many possible resolutions from the exhaustive Cause Map than the generalized high-level analysis (Leape & Berwick, 2000).

Root Cause Analysis is one of the most commonly used approaches to recuperating patient safety, but surprisingly, few records exist to support its efficiency. Much of the problem though lies in how Root Cause Analyses are interpreted instead of how they are performed, given that there is no consensus on how infirmaries should analyze Root Cause Analysis data. This restricts the utility of Root Cause Analysis as a quality advancement tool. Generally, Root Cause Analysis if an efficient tool for identifying as well as solving problems.

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