Legal Incident Reporting Requirements

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The Agency for Health Care and Research and Quality defines the term as “a structured method that is used to analyze adverse events” (AHRQ, 2012, n.p). Wu et al (2008) points out that it was developed so as to explain the basic and causal factors that underlie performance. Root care analysis as used in health care is the process of scrutinizing serious occurrences that often border on fatalities by various medical teams by a group of people who have sound expertise in this area (Flanders and Saint, 2005). It was originally designed for psychology and engineering but has expanded in application to other areas such as health care and administration. The analysis seeks to answer three basic questions: what happened, why  and how it happened to prevent future occurrence of the same (Wu et al, 2008). Root cause analysis is a reactive method meaning that it is used after the problem has occurred. Through analysis of present problems, root cause analysis is intended to be a preemptive incident management strategy (Okes, 2009). It can also be used to forecast the occurrence of similar or related incidences in future.

Problem Identification

The problem in the case study is the wrongful administration of dosage on a critically ill patient. On admission, the patient received various treatments for his symptoms. There are changes that are made in the drugs that are administered to him. For instance, there is the discontinuation of norepinephrine. There is some negligence primarily by the resident who administers the vasopressin. Despite there being a dosage of vasopressin on the computerized physician order entry system, the resident does not check this. The problem goes undetected for 16 hours, which aggravated the patient’s condition as a result of the overdose (Flanders and Saint, 2005). Even more worrying is that the mistake was not discovered by the primary care givers in the hospitals. There is a high chance that the problem would have gone unnoticed in the normal hospital operations. A root cause analysis is necessary in this case study because it highlights things as such negligence of the health professionals, poor coordination of the staff in the hospital and lack of effective protocol in the supervision of critical patients and administration of drugs.

The problem should be investigated. Flanders and Saint (2005) mention that this is common: “Clinicians who regularly care for hospitalized patients—particularly the ill, often observe medical mistakes.” The problem also has the potential to lead to negative consequences on the patients involved. These incidences take place in the Intensive care unit of the hospital and patients here are especially prone to succumbing to the effects of such errors. The hospital administration faces legal consequences as a result of such incidences. Indeed, hospitals are required to report such incidences. The Minnesota Department of Health requires hospitals to report errors involving wrong dosage. This is especially so if there is a disability occurring as a result of the errors that occur as a result of the error in dosage (Minnesota department of Health, n.d). The results of the investigations will enable the hospital to take measures to prevent the occurrences of such incidences and the resultant consequences.

Goals of Root Cause Analysis

The primary purpose of Root cause analysis is to pin point the elements that led to the variable characteristics of a particular incidence, and its consequences. These variables include the nature, timing, location, and magnitude. These variables ensure that the problem is identified clearly. Often organizations make the mistake of assuming that Root Cause analysis leads to the identification of one main problem. As seen in the case study, there were several problems that led to the particular event. Indeed, as seen in the case study, the problems are largely independent and even affect different parts of the organization. It is necessary to identify all the problems and their magnitudes.

The second purpose is to formulate solutions for the found problems so as to eliminate or significantly reduce the occurrences of the occurrences. These measures are presented as reports of the root cause analysis. These reports suggest modification or enhancement of processes that navigate the organization’s business of the day or specific processes (Andersen et al, 2009). It exploits structural nature of the organization through its analysis for weaknesses and strengths to formulate solutions for the root causes found. These solutions in the short term solve the problem triggering the root cause analysis and in the long term validate and justify the process itself (Okes, 2009).

Limitation of Root Cause Analysis

The limitations faced in root cause analysis are caused by its inherent assumptions that are in its definition. Indeed, the term root makes the assumption that the problems that are found have no internal complexities of their own. It also assumes that the problems found are independent. These two assumptions are likely to emerge but are not common. Solutions that are implemented to eliminate the changes found may end up exacerbating the problem. This thus creates a difficulty that results in causality webs (Okes, 2009). Causality webs often indicate the need for large scale changes in the organization and thus it is assumed that a few changes in the organization are enough to solve the problem. This may work in the short term, but the problem recurs when overlooked elements take effect.

Root cause analysis also leads to analysis paralysis. This occurs when the problems that are established are in their nature difficult to solve. Usually the organization is unable to deal with the aspects that all those involved are able to realize but difficult to acknowledge (Andersen et al, 2009). This is common in problems that result in conflict among those involved. Lastly, in health care, there is the controversial question on whether the risk of recurrence of the problem is reduced after the root cause analysis (Wu et al, 2008).

Steps in Conducting Root Cause Analysis

The first step is the identification of the analysis team to conduct the analysis. The team should consist of individuals who have the ability to contribute effectively to the analysis process. The team leader should be drawn from the quality management team of the organization independent of the department that incidence occurred (Flanders and Saint, 2005)

The team should identify and describe the problem. This involves identifying the attributes of the problem that may be quantitative or/and qualitative. This involved describing the aforementioned variables of magnitude, nature and place.

Thirdly, the team should gather the relevant data and evidence and arrange it in chronological order to the occurrence of the incidence. The causes found should be divided into those that contribute to the sequential chain of events and root causes. Root causes are those that if removed would eliminate or disrupt the occurrence of the incident.

The team should formulate corrective actions that would eliminate or reduce the occurrence of the incident. If possible measures that mitigate the consequences of the incident can be mentioned. This is in areas where the incidence is unavoidable.

The recommended solutions are then implemented. The root cause analysis program should also be measured for success. Failure for this measurement results in the whole process being a trial and error. To measure this success, various things can be assessed. They include: the ratio of the analysis conducted and incidences that trigger analysis. Also, amount of time spent reacting to incidences, frequency and severity of the incidences before and after analysis.