attending root cause analysis

[nite-owl]

Need advice please!

I'm being asked to attend a root cause analysis on a pt. This pt came in with migraines nothing was helping after a week was going to be transferred to a different hospital with a neuro dept. The previous night before i took care of this pt she developed incontinence episodes of confusion and had starring episodes which continued off and on through the following day (docs were aware of this). When I rec'd pt behavior was approp, later that night incontinence began again and pt would only follow a few commands all vs stable. Notified two docs one came to write orders then left without seeing her the other would be in first thing in am. So when doc came in in am they suspected she was seizing. Pt was later transferred to icu before going to other hospital. I've never been involved in an RCA and don't know what to expect, it's just scary.

[iNurseUK, RN]

It is very scary. I had to attend one of these about a patient who developed aphasia after bowel surgery and no-one noticed until I picked it up on nights (he had a CVA).

Basically you will be asked what you observed about the patient, what changes there were and what action you took. From your account you did nothing wrong. You took appropriate action (notifying docs) If the doc then failed to review the patient then that is their fault not yours.

You reported a deteriorating patient. The doctors failed to see and review the patient appropriately. As long as you have it all documented you are in the clear.

[classicdame, MSN, EdD]

I would think they might ask about your chain of command. At least be prepared to answer why you did not use the C/C if you did not get resolution from the MD. We can all think of what we should do/say AFTER the event, but during it is something else. Good luck!

[j621d]

I've sat in on root cause analysis (as part of my job), and yes, it is scary and intimidating. The purpose is to find out exactly what happened, when did it happen and what was done, etc. Sometimes it can get very detailed, but the purpose is to determine what can be learned from the situation. They are not necessarily looking at nursing, but it may be to see how others interacted in the situation.

Just take a deep breath and answer to the best of your ability. The bottom line should be to discover how to improve patient care.

[nite-owl]

Thank you all for you're input.

[canchaser, BSN, RN]

This is not to find blame in a person. It's to find where the system failed the pt. I went thru one. I'm glad I did, all the rumors, hearsay around the unit, self doubt about what I could of done better. It all ended at the RCA. There is no way to prepare, there will be a small narrative of your and others charting leading up to the event in question. It's kinda like a debriefing. Good luck and relax.