ROOT CAUSE ANALYSIS
Root Cause analysis (RCA) identifies the root causes of events and problems and seeks problem-solving methods (Anderson & Fagerhaug, 2000). Root Cause analysis believes that instead of addressing a problem by the obvious symptoms it is better to attempt eliminating or correcting the root causes. Root cause analysis methods contain different processes, tools and philosophies.
One of the methods is safety-based which descends from occupational safety and health and accident analysis (Robitaille, 2003). In order to provide high quality health care, Root cause analysis insists that patient safety should be a fundamental element. All healthcare organizations and professional should make safe healthcare a priority.
In the case, whereby a patient was misidentified due to sample mislabeling, Root cause analysis provides for the safety precautions and procedures that should be taken (ISO 15189, 2003). The patient had arrived in the hospital suffering from right ankle fracture. A radiograph was supposed to be taken so that she could be operated on. The technician in charge confused the samples and wrote her name on the sample that had a left ankle surgery. The patient was therefore taken to the operation room and anesthesia administered before the doctor realized the mistake and did another radiograph.
The issue of mislabeled patients is not so common but they happen in our health care showing an example of failures in institutions. In case of a mislabeled patient, root cause analysis provides for three steps solution. First, the problem has to be defined by asking questions such as what the problem is, when it happened and where and the impact (Anderson & Fagerhaug, 2000). From the case the problem is that the patient could have undergone a wrong procedure due to radiograph mislabeling. The problem occurred on the hospital’s operating room while the patient was awaiting surgery.
The next step includes identifying the cause of the problem (Health Canada Health Care System, 2004). The analysis of the cause- effect relationship is filled in a cause map. The cause map explains the systematic process of the problem by asking questions and answering them. In this case, the patient was administered anesthesia because he was prepared for the surgery. She was prepared for surgery because of orthopedists recommendation. The orthopedist recommended the surgery because he believed the patient had a fractured ankle. The orthopedist performed an ineffective exam because he did not review the radiograph and the patient and her family did not confirm the patient diagnosis. The near miss might have been avoided if one of these causes failed to happen. In our scenario, the cause of mislabeling and the reason why the orthopedist did not review the radiograph is not known. After the problem is analyzed using the cause map, best solutions are selected that would reduce the risk and recurrence of the incident in the future. The cause map must have detailed supporting evidence (McDermott, Mikulak and Beauregard, 1996).
Anderson B., Fagerhaug T. (2000), Root Cause Analysis: Simplified Tools and Techniques, Milwaukee, WI: ASQ Press
Health Canada Health Care System. (2004), Patient Safety, Retrieved on April 6, 2010 from
ISO 15189. (2003), Medical Laboratories – Particular Requirements for Quality and Competence.
McDermott, Mikulak and Beauregard. (1996), The Basics of FMEA. New York, NY: Productivity Press
Robitaille, D. (2003), The Preventative Action Handbook. Chico, CA: Paton Press