Final Project Milestone One: Root Cause Analysis and Patient Safety Strategies
Karen Viani was newly diagnosed with congestive heart failure one month ago. Her primary physician prescribed a number of medications: a beta blocker to slow her heart rate, Lasix to treat the fluid overload, and digoxin for control of her symptoms. She also takes a potassium supplement. Ms. Viani is 76 years old, slim, and lives with her pet dog, Alfredo.
She was hospitalized on Friday at noon at Mesa Valley Hospital, a 60-bed acute-care facility. This was after seeing her primary doctor for increased shortness of breath and after gaining four pounds in 24 hours. The hospitalist ordered a one-time dose of Lasix 20mg IV on admission followed by a lab order to check electrolytes in one hour.
Recent hospital patient safety survey results identified some areas of strength and weakness. Strong positive responses were in the categories of organizational learning and continuous improvement at 78%; teamwork also scored a high 80% positive response. Areas with potential for improvement were staffing at a positive response rate of 25% and non-punitive environment and safety culture had a positive response rate of 20%.
The nurse responsible for care of Ms. Viani was very busy. She gave the Lasix three hours after Mrs. Viani arrived and after the lab had drawn the blood for the electrolytes. When the hospitalist arrived at 1630, she noted the lab report indicated that the potassium level was low. The hospitalist assumed that the blood was drawn after Ms. Viani had received the Lasix.
The hospitalist ordered another Lasix 20 mg IV. The evening nurse noted the order at 1700 and gave the Lasix before dinner.
During the evening mealtime, Ms. Viani suddenly felt light-headed, tried to reach the call bell that was on the bedside table, and fell on the floor. Ms. Viani sustained a small laceration on her forehead and a sprained right wrist, and then became quite disoriented and lost consciousness for a few seconds. The rapid response team (RRT) was notified and by the time the team arrived, Ms. Viani was lucid and was complaining of pain in her right wrist. The hospitalist ordered in the patient’s record that an incident report needed to be filed as the nurse made a medication error. The hospitalist has professional liability insurance as a condition of her employment at Mesa Valley. The nurse does not.
For your first step in developing your error analysis and recommendations paper, you will select one of the case studies from the Final Project Case Studies
document to be the focus of your entire project. You will then complete a root cause analysis and recommend appropriate patient safety strategies. Remember,
this is your first draft. You will have an opportunity to incorporate suggestions from your instructor and course content in later modules prior to submitting your
final version in Module Seven.
In this first milestone, the following critical elements must be addressed:
I. Root Cause Analysis (RCA): In this section, you will provide an overview of the details in the provided case study that led to adverse patient outcomes.
This overview will be in the form of a flowchart, which you will then use to help you analyze the medical error. Specifically, you should include the
A. Timeline: Using a flowchart, summarize the events, processes, and staff involved in the timeline of events that led to the medical error.
B. Factors: Based on your flowchart, use a modified root cause analysis to do the following:
i. Identify two contributing factors that led to the medical error
ii. Identify one causal factor that led to the medical error
Hint: For help with the RCA, refer back to your work relating to the AHRQ website in Module One.
II. Patient Safety Strategies: In this section, you will use the factors you identified to recommend a measurable evidence-based patient safety
improvement strategy. Specifically, you should include the following:
A. Recommendation: Based on the contributing factors or causal factor that you identified, recommend an evidence-based patientsafety
improvement strategy. What role would patients and families have in your recommendation?
B. Measurement: How will the strategy be measured so that medicalstaff can determine whether the strategy led to improved patient safety? In
other words, what will the primary measure be? What types of data should be collected?