CLC_Root Cause Analysis_Group Project

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HCA 450

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Feb 20, 2024

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CLC - Root Cause Analysis Trisha Dutrow, Samantha Mundle, Ecstasy Richard, Letisha Morgan, Chelse Muterspaugh Grand Canyon University HCA - 460 Professor Thacker February 10, 2024

CLC - Root Cause Analysis There are many ways that quality can be improved throughout a healthcare organization. One of the best ways to improve quality is by doing a root cause analysis. A root cause analysis is the process of finding the root cause of a problem to identify a solutional to the given situation. A root cause analysis can be used for patients who falls in healthcare. The process can help determine how and why patients are falling suddenly, while helping healthcare staff on the next steps. One of the root cause analysis tools is called the fishbone diagram. The fishbone diagram allows for the visualization of multiple factors contributing to a problem. Since patient falls can have various causes such as medical history, age, lack of communication, and absence of devices, this tool can capture the complexity of the issue. Major Root Cause A major problem that most healthcare organizations face is patient falls. Patient falls can lead to either patient injuries or even death. Significant root causes in association with patient falls include medical history of the patient, age, lack of communication between staff, and absence of devices such as walkers or a cane (Ruddick, n.d.). The latter instance of patient falls could help leaders establish the contributing factor for patient falls. Reviewing incident reports and the patient's medical records will help establish why the fall occurred. Understanding the root cause of the patient's fall will help the healthcare organization take necessary actions to establish a prevention plan. Lastly, a major problem that is associated with patients falls in the plausibility of them ensuing litigation against the healthcare organization. Ensuing litigation against the facility could potentially cost the organization thousands of dollars in settlements, especially if the patient has to stay longer in the facility due to the fall.

Relevant Stakeholders There are many different stakeholders when it comes down to patient fall prevention. The main stakeholders are fall prevention champions, healthcare team members and other partnering healthcare professionals. The professionals are responsible for providing direct patient care to be able to prevent patients from falling, which happens too often in different healthcare facilities. Stakeholders come up with different strategies for fall prevention. Some of the strategies include providing more oversight and care for the patients who are deemed to be at risk of a fall. Preventing falls is highly recommended for older adults who are receiving different types of services such as home care services or assisted living services. “Patients' experience falls more often while hospitals and facilities are minimizing them” (Alanazi,2023). Adults who are over the age of sixty experience falls annually due to bodies growing older and body functions becoming limited due to many different causes. The stakeholders come from all different aspects of healthcare, and they are the most important to the patients by receiving services. Fall prevention champions and healthcare professions work together to come up with different ways in helping to prevent future patient falls if they can be avoided all together. Root Cause Analysis Process Root Cause Analysis (RCA) is a systematic approach used in healthcare to understand the underlying causes of adverse events such as patient falls. In the context of Banner Health, conducting a thorough RCA for patient falls necessitates gathering comprehensive data and information across various domains. The first critical aspect of RCA is obtaining detailed information about the fall incident itself. This includes the date, time, and location of the event, as well as the circumstances surrounding it. Understanding the context in which the fall occurred

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is crucial for identifying potential contributing factors ( Rooney,2004). Next gathering the patient information is essential, such as age, gender, and ethnicity can help identify patterns or trends in fall occurrences. Demographics, medical history, mobility status, cognitive function, medications, and any existing fall risk assessments or care plans are also essential. The competence and preparedness of healthcare staff play a significant role in fall prevention and patient safety. Staffing levels, qualifications, training completion status, and competency assessments related to fall prevention and patient safety. Assessing staff competency in implementing fall prevention strategies enables identifying potential gaps in knowledge or skill. The physical environment in which the fall occurred can contribute to or mitigate fall risk. Conducting thorough environmental assessments involves examining factors such as lighting, flooring, furniture arrangement, and equipment accessibility. Inspection reports and safety audits are valuable information regarding the safety features and potential hazards within the healthcare facility. Lastly, accurate documentation and communication of patient care interactions is fundamental. Analyzing communication patterns and documentation practices can reveal breakdowns or deficiencies in care coordination, potentially contributing to the fall incident. Several strategies have been determined to be effective in reducing falls. ( Mills,2005). Root Cause Analysis Tool The most suitable tool for conducting a root cause analysis would be the fishbone diagram. The fishbone diagram allows for the visualization of multiple factors contributing to a problem. Since patient falls can have various causes such as medical history, age, lack of communication, and absence of devices, this tool can capture the complexity of the issue. It also provides a structured approach to identifying potential causes by categorizing them into specific branches related to different aspects like people, processes, equipment, environment, and

management. This structured analysis is beneficial in understanding the interrelationships between different factors contributing to patient falls. The creation of a fishbone diagram often involves a team, which encourages collaboration and different perspectives. Given that patient falls can involve various stakeholders such as medical staff and administrative personnel, involving a multidisciplinary team in the analysis can lead to a more comprehensive understanding of the problem. One great benefit of the fishbone diagram is that because it is so visual it makes it easier to communicate findings and insights to stakeholders. This visual representation can facilitate discussions and decision-making regarding potential interventions and prevention strategies. While other tools such as the Pareto chart, 5 Whys, or FMEA could also be useful in certain contexts, the fishbone diagram appears to be the most appropriate choice given the complexity and multifactorial nature of patient falls in healthcare settings. Additional Helpful Information and Approach Utilized To perform a thorough root cause analysis (RCA) for patient falls in healthcare settings, additional information must be gathered in addition to what was covered in the first analysis. "Risk management in health care institutions requires a multifaceted approach that considers various aspects contributing to adverse events," as Kavaler and Alexander (2014) emphasize. Therefore, it would be helpful to gather information on personnel levels and workload, as well as staff training and proficiency in fall prevention techniques, in addition to the incident reports and patient medical records indicated. Moreover, the context for comprehending the systemic reasons causing patient falls can be provided by knowledge of the organizational culture and patient safety rules. Martin Delgado et al. (2020) highlight that adding patient viewpoints using surveys ‐ or interviews may improve the root cause analysis process by providing insightful information about things like patient comfort and mobility in the hospital setting.

The team's systematic approach to root cause analysis (RCA) entails a review of several patient fall-related factors, such as patient demographics, medical history, staff competency, surrounding conditions, and communication strategies. The team hopes to determine the underlying causes of patient falls and create successful preventative methods by collecting thorough data in each of these domains. This method is in line with best practices in RCA since it stresses the value of a multidisciplinary viewpoint in the analysis of adverse occurrences and considers a number of contributing elements. Several sources of information were used to conduct the root cause analysis, including incident reports, patient medical records, staffing data, environmental assessments, and communication audits. Many factors, including patient characteristics, staff readiness, environmental dangers, and care coordination procedures, are discussed in these sources in order to shed light on the various facets that contribute to patient falls. Through the process of integrating information from various sources, the team could gain an in-depth understanding of the elements that lead to patient falls and pinpoint prospects for enhancing fall prevention tactics. Conclusion In conclusion, conducting a thorough RCA for patient falls at Banner Health necessitates gathering comprehensive data and information across multiple dimensions. By analyzing incident details, patient information, staffing and training records, environmental assessments, and documentation and communication practices, healthcare organizations can identify root causes and implement targeted interventions to prevent future occurrences. There are many ways that quality can be improved throughout a healthcare organization. One of the best ways to improve quality is by doing a root cause analysis. Significant root causes in association with

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patient falls include medical history of the patient, age, lack of communication between staff, and absence of devices such as walkers or a cane (Ruddick, n.d.).

Reference Page Alanazi, F. K., Lapkin, S., Molloy, L., & Sim, J. (2023). The impact of safety culture, quality of care, missed care and nurse staffing on patient falls: A multisource association study. Journal of Clinical Nursing , 32 (19–20), 7260–7272. https://doi-org.lopes.idm.oclc.org/10.1111/jocn.16792 Kavaler, F., & Alexander, R. (2014). Risk management in health care institutions: Limiting liability and enhancing care (3rd ed.). Philadelphia, PA:Jones & Bartlett. Martin ‐ Delgado, J., Martínez-García, A., Aranaz, J. M., Valencia-Martín, J. L., & Mira, J. J. Systematic Review. Medical Principles and Practice, 29(6), 524– 531. https://doi.org/10.1159/000508677 Mills, P. D., Neily, J., Luan, D., Stalhandske, E., & Weeks, W. B. (2005). Using aggregate root cause analysis to reduce falls and related injuries. The Joint Commission Journal on Quality and Patient Safety , 31 (1), 21-31. Ruddick, P., Hannah, K., Schade, P, C., Bellamy, G., Brehm, J., & Lomely, D. (n.d.). Using root cause analysis to reduce falls in rural health care facilities. https://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Ruddick_61.pdf Rooney, J. J., & Heuvel, L. N. V. (2004). Root cause analysis for beginners. Quality progress , 37 (7), 45-56. Ungvarsky, J. (2023). Ishikawa diagram. Salem Press Encyclopedia.

CLC_Root Cause Analysis_Group Project

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