Root Cause Analysis

Root Cause Analysis in Healthcare
Heidi Serrano Vargas
Southern Polytechnic State University

Summary
In the article “Root cause analysis of transfusion error: identifying causes to implement changes” the authors explain the process followed to find the causes for an incident involving two patients with the same name and a missing blood transfusion sample. This incident happened in India,where technology is not linked to the standard patient admission procedures like it is done in the United States. The main purpose for conducting a root cause analysis for the transfusion error was to eventually provide a base of facts through the identification process that would result in the implementation of permanent changes to improve the process and avoid incidents that could lead to thedeath of patients. The analysis was possible thanks to an error reporting system prototype which aim was “identifying deficiencies and lapses for taking corrective action” (Elhence, Veena, Sharma & Chaudhary, 2010, p. 2772). After the analysis, the hospital started and information and training campaign to remind the employees of the SOP’s to follow. The necessity to link technology and the humanfactor was also brought up as one of the implementation measures as a consequence of the root cause analysis.
Author’s Main Point
No adverse event is a coincidence. That was the mentality present when attempting to acquire data that would significantly show an urgent need for the implementation of standards to guard transfusion safety principles. The root analysis method followed and describedin the article had one main goal to satisfy: keeping patients safe and learning from near miss accidents over adverse transfusions. Error recognition and reporting with the intention of improving a hospital’s blood transfusion program was the focus of the root cause analysis instead of the need to punish and find responsible employees for an incident.
Having appropriate tools to collect andkeep data organized rapidly showed its value when converting a simple missing blood transfusion sample into a “high event severity level error” incident that reflected not one, but five different breaches. Having the right attitude is also key, which the author described as a “proactive non-punitive approach” by getting information from the people that were involved in the incident (Elhence, Veena,Sharma & Chaudhary, 2010, p. 2774).

Problems, Limitations, and Ideas for Improvement
Lack of technology, training, and SOP’s enforcement are some of the challenges that third world countries will face to efficiently identify events and conduct statistic based studies to improve the outcomes of services like blood transfusions. As the article itself describes, if it has notbeen for the prototype the root cause analysis based on Jennifer Smith (patient 1) and Jennifer (patient 2) would have not taken place because it could have been treated as a one-time occurrence that did not have an adverse consequence. And that is exactly were the problem identification lies, in the unknown reason, which brings up the 5 WHY’s approach as an example. The case report is a perfect5 WHY’s analysis but the authors did not refer to it with that name on the article. It would have been great to see that reference because it is one of the concepts used in the root cause analysis that the healthcare industry is taking advantage from in their investigations. Sherwin discusses the basics of root cause analysis in her article about contemporary topics which give healthcareprofessionals an insight of using the 5 WHY’s in basic root cause analysis and an explanation of how to use it to implement solutions.

Article Potential Effects or Limitations
This article serves as an example to the concepts discussed in class for the implementation step. It provided a clear scenario of why it is important to fully understand what the mission of the service provider to continue...