Wound Root Cause Analysis

[Cardiackid17]

Hello everyone,

Just wanting to get some feedback on what is considered appropriate for escalating a wound/skin alteration to administration for root cause analysis. Currently working in a critical care unit with a director who wants root cause analysis for ALL wound/skin alterations that develop in the unit. All involved staff that has ever worked with the patient will attend these meetings. I see the benefit in these RCA's however, also believe in auditing the whole situation as in the current disease state, contributing factors and so on. For example, a bed bound patient post failed fem-pop bypass acquires a DTI in affected extremity, an RCA is being conducted for. Have never been asked to attend an RCA, what is to be expected and bottom line is admin trying to assign blame in these cases? Thanks for your input!

[MunoRN, RN]

Ideally it shouldn't be about assigning blame, although there are certainly managers and other administrators who will view it that way.

I do think it's appropriate to look into every event of avoidable harm in the ICU for the purpose of better avoiding similar incidents in the future. That doesn't mean that pressure ulcers and other "incidents" are reasonably avoidable, but that should be part of what an RCA determines. RCA's that start with the premise that something was definitely avoidable have failed before they even begin.

[MunoRN, RN]

I should add that in most of the RCAs I do on avoidable skin events they turn out to be based on an incorrectly identified pressure ulcer, with suspected DTI's being the most common, we sometimes need to be reminded that not every bruise, hematoma, etc is a DTI.