What to Expect - Root Cause Analysis

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Specializes in critical care.

I had a reasonably healthy, very elderly lady yesterday. New onset CHF, day 2 of admission. Diuresing perfectly, not a single complaint except uncomfortable foley (found an overinflated balloon when removing it). No crackles, was walkie/talkie, EF 50-55, some regurg in a couple of valves (m&t I think?), elevated PAP (40s) (that echo was yesterday).

Did sundown at night. A&O during the day, though. No s&s of bleeding, no abnormal labs except BNP, which was not all that impressive. Just high enough to get the diagnosis and a room. Her whole reason for coming in was some shortness of breath that didn't want to go away for 2 weeks.

So today, she suddenly died. I didn't have her today, but her nurse says she was sleepy in the morning, seemed totally okay, suddenly decompensated, and coded. No clue what happened.

My understanding of root cause analyses is that they're turned to when there is a surprise like this one. With her being nearly 100, perhaps it won't go that direction? Are RCAs only initiated and done in house? Or do outside people get involved? If one is initiated, is this an instance where I should get in touch with NSO (my carrier)?

The nurse who had her actually switched shifts with me. He was supposed to have her yesterday, and I was supposed to have her today. Poor kid..... He's so fresh out of school. I'm sure this has messed with his head a bit.

A must read article on Root Cause Analysis... (added by staff May 2018)

https://allnurses.com/nursing-issues-patient/ive-been-quot-1155624.html

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Specializes in Emergency, Telemetry, Transplant.

I don't know very much about RCAs and the legalities of them.

All I will say--hang in there. I know this sounds really cold, but old people die--especially ones with comorbidities. It does not take much of an illness--their bodies just can't handle the stress of being sick like a younger body can. You should definitely learn what you can from it, but, it happens.

Also, make sure this new nurse knows that it was not his fault! It might mess with his head, but start right now making sure his head stays in the right place, and this had nothing to do with the nursing care he provided.

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Specializes in Healthcare risk management and liability.

I do RCAs, amongst other things, for a living. Doing one is usually triggered by a sentinel event or critical incident. There are some standardized (TJC) definitions for these, if your facility follows them. Different facilities have different levels of enthusiasm for doing RCAs for events like these. They are time and resource intensive to conduct. If your facility does not have someone in house (usually risk, quality, patient safety, legal or administration) who can do RCAs, then you can bring in someone from outside and I have played that role at some places. Most facilities do them in house, though.

Don't freak out about a RCA. It is just a structured approach to find out the reason why something happened, learn from the event, and figure out if we can or should make any changes to systems or processes to reduce the risk of the same event occurring again in the future. Sometimes the finding is bad things happen to good people, and they cannot always be prevented or mitigated.

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Specializes in Oncology.

The RCA I participated in was vastly different. There was a terrible med error that went missed for nearly 12 hours and involved 3 different nurses finagling with the drip and not realizing it was running incorrectly. It was a drip running on a unit it shouldn't have been on, on a patient that was too unstable for that particular unit, with nurses that don't normally work on that unit. The error easily could have been fatal, but remarkably, the patient made is through unscathed. So essentially the opposite scenario.

It was weird having my charting from that day laid out in front of me for the committee. It gave me a whole new respect for how I chart. I appreciated the non-judgemental attitude everyone took. The truly did approach it as a systems failure. They seemed to appreciate hearing things from a nursing perspective.

Immediately after the RCA things started changing, and despite the changes other people managed to make similar errors. Now they've made such extensive changes that there's no possible way this specific error could be made again.

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Specializes in Neuro ICU and Med Surg.

I was involved in a RCA with a lumbar drain. It totally changed the system that we used for our drain.

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Why does your manager want to initiate a RCA? There is no need. The patient was quite elderly and sometimes when a very elderly patient is admitted, even if they were functional beforehand, they quickly decompensate.

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Specializes in Emergency.

Ask for union rep if you have one, request chart notes, answer questions directly & succinctly, do not volunteer information, think before you speak. This advice is really if you have a "blame" culture.

RCA's when done correctly will address system issues which are usually (but not always) the root problem.

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Specializes in critical care.

Thank you everyone for your responses.

There has not been an "announcement" that one is being done (yet). I'm getting ahead of myself here, admittedly. I'm preparing myself in case it does happen. This lady was old and old people die. I do appreciate that fact. It's the fact that absolutely nothing about the way she presented (except maybe here PAP) indicated she would pass so unexpectedly. If I were her family, I would be asking a lot of questions. If I were administration, I'd be researching to answer them. Will it lead to a RCA? I'm not sure, but I'm making sure I'm proactive in case they do.

It is good to hear the non-judgment experience. I've been very fortunate to not feel a feeling of blame culture. In fact.... There was a recent incident that was reported in which it is uncertain whether I was at fault. Ultimately the situation was my responsibility, but how it came to be, I don't know. I was questioned, I shared what I knew, I took responsibility and explained how I'd do things in the future, but there was no point in that conversation at all where the manager pointed any fingers or placed any blame. I imagine if a RCA is conducted in house, it will hopefully be more on the non-judgment side than the blame side. God, I hope!

So, should I contact NSO, or wait to see if the family even initiates anything? Or am I really over thinking this completely?

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Specializes in Healthcare risk management and liability.

^^^I think you are overthinking this and are needlessly concerned. You should call NSO and see what they tell you, and report back.

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Specializes in critical care.

Thank you :)

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Specializes in Critical Care, Education.

Participation in a well-executed RCA is an excellent learning opportunity. They can produce findings that have a significant impact on the practices and processes in an organization. We use HFACS -(Human Factors Analysis and Classification System) as a basis for our RCAs. It was originally developed by the airline industry to analyze accidents. It's very effective.

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Specializes in critical care.

I haven't been able to call NSO because I've been working, but I did want to come back and update. As of right now, it appears nothing is being pursued. The thought is a possible bowel perforation, but without more information, it's a shot in the dark. The family is understanding (old = death does happen), and so it appears all is uncomplicated.

Thank you for all of your responses. I do think I'd like to call NSO just to see what would have been said by them. I'll update next week with that (since it's Friday and I do work).

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