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The value of a root cause analysis

November 1, 2008
by Linda Williams, RN
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In recent years, a special focus of the Centers for Medicare & Medicaid Services, as well as the healthcare industry in general, has been the need for providers to ensure safe resident environments. By using a systematic approach to identify and evaluate hazards and risks, implementation of effective interventions can reduce or eliminate these dangers altogether. Such an approach is not easy, as it requires purposeful analytical skills and a thorough understanding of the investigative process that usually involves a root cause analysis. If conducted properly, a root cause analysis will enable the investigator to (1) isolate the circumstances that increased the risk of an accident or incident from occurring; (2) determine who or what was involved in the situation; and (3) assess whether the facility might have control over the causes of the event.

Once an investigator has identified a root cause, implementing effective interventions should be easy. Please analyze the following circumstances to see what problems and contributory causes you can identify, as well as the changes you would make if this situation occurred in your facility.

The situation

As a nurse entered a hospital to conduct a nursing home preadmission assessment of an 82-year-old woman about to be discharged, she came across the woman's daughter at the nurse's station. The daughter was in the process of anxiously reporting that her mother was having difficulty breathing, so the staff nurse grabbed a pulse oximeter and headed toward the woman's room. Her supplemental oxygen had been off for 15 minutes so a lab technician could obtain an arterial blood gas (ABG) sample on room air, so her respirations were uneven and slightly labored. Once the technician was finished, the woman's oxygen nasal cannula was replaced and the pulse oximeter soon indicated acceptable saturation levels.

Although the patient remained pale, she was nevertheless alert and oriented enough to converse appropriately with the nurse (from the nursing home) that came to interview her. Both she and her daughter voiced concerns about her premature discharge from the hospital and neither indicated a full understanding of the patient's overall health and prognosis. Her diagnoses included left lobe pneumonia, asthma, congestive heart failure (CHF), essential hypertension, and osteoporosis. Before leaving, the nurse reassured them that she would ask the hospital discharge planner to talk to them about their concerns.

Despite an initial reluctance, the woman was admitted to the nursing home later that afternoon. She arrived with mild dyspnea and required continuous supplemental oxygen at 3L per nasal cannula. Her physician wrote an order to “keep oxygen saturation levels greater than or equal to 90%.” The woman was exhausted, so the staff hurriedly completed their admittance paperwork and then encouraged her to rest while they periodically checked her.

The woman slept comfortably for the next three hours, until a certified nursing assistant (CNA) discovered her sitting at the end of the bed. She asked the CNA for help to the bathroom and then requested to sit in a chair near her bed. During the process, the CNA removed her nasal cannula because the tubing was not long enough for her to move about. Throughout the ordeal, the woman did not appear to be in any respiratory distress.

About 30 minutes later, the woman's daughter entered the room and found her sitting in the chair without her supplemental oxygen. The daughter became upset and summoned the charge nurse, who immediately reapplied the woman's oxygen. The daughter then insisted that her mother be placed back in bed. However, the woman wanted to stay in her chair and so the two argued, which caused the woman to become very upset. She finally gave in, and was assisted back in her bed, but she insisted on sitting on the edge instead of lying down.

About this time, the woman's son arrived and expressed concerns that his mother was discharged too soon from the hospital. He asked the charge nurse if his mother should be sent to the emergency room. The nurse examined the woman and felt that she was not in any acute distress. However, the daughter insisted that she was, and so plans were made to transfer her back to the hospital after being in the nursing home just six hours.

At the hospital, a decision was made to admit her and soon thereafter the woman's condition deteriorated to the extent that she needed to be intubated. Meanwhile, the daughter remained angry with the staff at the nursing home and blamed them for her mother's decline. Upon hearing this, the administrative staff at the nursing home contacted the state survey agency to report the incident, as required by their state.

In response, a survey team was sent to the facility to investigate, and while there, news arrived that the woman had died. The survey team cited the facility for failing to ensure that continuous oxygen treatments were administered as ordered by the physician. When they asked the charge nurse what the woman's oxygen saturation levels were before reapplying the nasal cannula, she told them that she had not checked because the facility did not have a pulse oximeter.

Months later, the woman's daughter filed a wrongful death lawsuit against the facility. In its defense, their attorney argued that the short lapse in supplemental oxygen had no direct bearing on the woman's outcome. However, a settlement was eventually agreed upon for $302,000.