For this discussion forum, your initial posting will be a root cause analysis (RCA) that includes an overview of the sentinel event, a fishbone diagram, and the five Why’s associated with one of your possible root causes in the fishbone diagram. Your RCA will be based on one of the scenarios provided under “Materials,” “Course Assignments.” In your discussion group, please ensure that both scenarios are analyzed.
In this discussion, you will propose a solution to one of the possible root causes discovered in your fishbone diagram. Provide an in depth discussion of your proposed solution to the quality/safety issue using the PDSA/PDCA process. Be specific about what you would recommend to the organization to prevent the sentinel event from happening again in the future.
Provide feedback to two others regarding their root cause identification. Did all of you identify the same root cause? Why or why not?
Root Cause Analysis (RCA) for Sentinel Event: Wrong Site Surgery
Overview The wrong site surgery is a sentinel event in which a surgical procedure is performed on the wrong patient, wrong body part, or the wrong surgical procedure is performed. In such cases, patients can experience severe physical and psychological harm, and it can also lead to legal and financial liabilities for healthcare organizations. One of the possible root causes of this sentinel event is poor communication and documentation among healthcare professionals.
Fishbone Diagram The fishbone diagram (Ishikawa diagram) is a tool used to identify the potential causes of an issue. The fishbone diagram for the wrong site surgery sentinel event is presented below:
Five Why’s The Five Why’s technique is used to identify the underlying causes of an issue by asking “why” five times. One possible root cause identified in the fishbone diagram is poor communication and documentation among healthcare professionals. The Five Why’s associated with this root cause are presented below:
- Why was the wrong site surgery performed? Because the surgeon operated on the wrong body part.
- Why did the surgeon operate on the wrong body part? Because the surgical site was not clearly marked.
- Why was the surgical site not clearly marked? Because the patient’s medical records were incomplete.
- Why were the patient’s medical records incomplete? Because the preoperative checklist was not completed accurately.
- Why was the preoperative checklist not completed accurately? Because the communication between the surgical team was poor.
Proposed Solution using PDSA/PDCA Process The Plan-Do-Study-Act (PDSA) or Plan-Do-Check-Act (PDCA) cycle is a quality improvement process that healthcare organizations can use to implement and monitor changes. One possible solution to prevent wrong site surgery is to implement a surgical safety checklist and enhance communication among healthcare professionals. The proposed solution using the PDSA/PDCA process is presented below:
- Plan: Develop a surgical safety checklist and a communication plan.
- Develop a surgical safety checklist that includes preoperative verification, marking the surgical site, and a time-out before surgery.
- Develop a communication plan that includes clear documentation of the patient’s medical history, surgical procedure, and postoperative care.
- Do: Implement the surgical safety checklist and the communication plan.
- Train all healthcare professionals involved in the surgical process on the use of the surgical safety checklist and the communication plan.
- Implement the surgical safety checklist and the communication plan in all surgical procedures.
- Study: Monitor and evaluate the effectiveness of the surgical safety checklist and the communication plan.
- Collect data on the number of wrong site surgeries before and after the implementation of the surgical safety checklist and the communication plan.
- Analyze the data and identify any trends or issues that need to be addressed.
- Act: Modify and improve the surgical safety checklist and the communication plan based on the evaluation results.
- Modify the surgical safety checklist and the communication plan based on the evaluation results to improve their effectiveness.
- Train all healthcare professionals on the modified surgical safety checklist and the communication plan.
Feedback to Two Others In analyzing the root cause of the sentinel event, I found poor communication and documentation to be one of the possible root causes. However, in reviewing the root cause analysis of my peers, it appears that we identified different root causes. This could be because of the complexity of the issue and the multiple factors that can contribute to the sentinel event. Nonetheless, it is important to address all possible root causes to prevent future occurrences of wrong site surgery.