Root Cause

Analysis
 Root Cause Analysis

Definition:
process for identifying the basic or contributing
factors that underlie variations in outcomes
Used to examine adverse events

- Definition: adverse events are unwanted

things happening; as used here, often they
happen over and over again
Used to examine close calls
Used to identify trends to prevent further
occurrences
 Root Cause Analysis
Most problems do not have an obvious solution - that is why
they remain problems
Or, you may not have realized that a problem even exists
Example, what should your facilitys rate of restraint use be?

What about pressure ulcers?

These dont mean that the facility isnt doing a good job, just that it
could do better!
Real objective is to improve the process at the fastest
possible rate
Root Cause Analysis leads to suggestions for improvement
 Root Cause Analysis
Errors usually result from faulty design of process, not
worker negligence
Poor design puts staff in situations where errors are
likely to occur
Example: No sink in room or hand sanitizers
(missed hand washing)
Example: No cleanser near bathroom (stinky
rooms)
Root cause analysis provides a path to figure out
how to correct problems and prevent further
occurrences
Assigning blame does not prevent reoccurrence
 Root Cause Analysis

Need to ask: Why? Why? Why?

Identify underlying functions leading to poor
outcome
Determine main or most important cause and all
the contributing factors you can think of
Usually begins by measuring components or
pieces of process
Think about each step in the process, and how
it can be measured
 Root Cause Analysis
Techniques

Organize a team with representation from a variety of

departments

Who will be included in:

Brainstorming
Identify barriers to favorable outcome
Collect data and sort to identify common threads or trends
Use fishbone
 Root Cause Analysis

The next step is for the team to brainstorm on

possible causes
Six categories.
1. Communication
2. Training
3. Staff Fatigue/Scheduling
4. Environment and Equipment
5. Rules/policies/Procedures
6. Barriers
For each category the team needs to decide if it was a factor
in the event being reviewed.
 Root Cause Analysis:
Rules of Causation
Causal statements must clearly show cause and effect
relationships
Reader needs to understand and follow your logic in links
(cause -effect conclusions)

Negative descriptors such as poorly or inadequate are not

used in causal statements
Broad, negative words do not describe actual conditions

Each human error must have a preceding cause

Must investigate why the error occurred
 Root Cause Analysis
Rules of Causation
Each procedural deviation must have a preceding cause
Example: why are steps to a procedure missed by the
nurse?
(example: Why is a daily pain assessment not performed?)

Failure to act is only causal when there was a pre-existing duty

to act
Duty may be assigned through regulation or standards of
practice
 Root Cause Analysis
1. Communication

The area of communications include questions such as:

Was the resident correctly identified?

Was existing documentation of treatment

plans clear?
 Root Cause Analysis
2. Training
Training includes questions such as:

Was training provided prior to the start of the

process?

Were the results of the training monitored over

time?
 Root Cause Analysis
3. Staff Fatigue/Scheduling
Questions in this section may include:

Did scheduling allow personnel adequate

sleep

Was the environment free of distractions?

Was fatigue properly anticipated?

 Root Cause Analysis
4. Environment and Equipment
Some questions for this area are:

Had there been an environmental risk assessment

of the area?

Was there a maintenance program in place to

maintain the equipment involved?
 Root Cause Analysis
5. Rules/Policies/Procedures
Some sample questions for this area include:

Were there written up-to-date policies and

procedures that addressed the work processes
related to the event?

Were relevant policies/procedures clear,

understandable, and readily available to all staff?
 Root Cause Analysis
6. Barriers
This area includes questions such as:

What barriers were involved in this event?

Would the event have been prevented if the

existing barriers had functioned correctly?
 Root Cause Analysis
Statements
Root Causes explain the teams findings about what
must be fixed
Root Causes guide everything else that follows
(task assignment, actions, outcome measures)

Strong Root Causes set up success

 Root Cause Analysis
Statement
The first step is writing a Root Cause Statement is
to pick the contributing factor that the team feels is
the strongest. The root cause statement is written
according to five simple rules
FIVE RULES
1. Show Cause and effect
2. Nothing negative about people
3. Fix systems, not people
4. Fix norms, not people
5. Duty to act
 Root Cause Analysis
Cause and Effect
WRONG:
A nurse was fatigued

RIGHT:
With overtime, nurses are often
scheduled more than 40 hours a week;
as a result, fatigued nurses are more
likely to misread instructions
 Root Cause Analysis
Rule 2. Nothing negative about people

WRONG:
Poorly written procedure

RIGHT:
The restraint procedure has 8 point font and
no illustrations; so staff dont use it,
increasing the likelihood that restraints are
applied incorrectly.
 Root Cause Analysis
Rule 3. Fix systems not people
WRONG:
Staff did not notice the resident was missing
for at least 8 hours

RIGHT:
Due to a malfunction in the door/vest
wandering alarm, a resident was able to elope
undetected
 Root Cause Analysis
Rule 4. Fix norms not people
WRONG:
Staff are waking patients at night

RIGHT:
Bathing policies and prn med passes need to
be adjusted to respect resident sleeping
preferences
 Root Cause Analysis
Rule 5. Duty to act

WRONG:
The nurse did not check for STAT orders

RIGHT:
The absence of an assignment for nurses to
check for STAT orders increased the
likelihood that STAT orders would be missed
or delayed
 Root Cause Analysis
Where do teams get stuck?
Lack of information (e.g., few interviews, few
references, limited or no simulation, limited
time, etc.)
Focus on too narrow a problem (saving one
particular patient)
Focus on too big a problem (saving the world)
 Root Cause Analysis
How to get teams un-stuck
Do more interviews
Check the literature
Check with professional colleagues (contact
similar facilities in different parts of the
country)
SIMULATE the event
Do some more brainstorming
Find the time to do the best job possible
Engage the medical director
 Root Cause Analysis
How to get teams un-stuck

Stick to/focus on the situation at hand

Focus on what can be done to help other
residents, families or staff in the future
Select bite-sized actions/outcome measures for
events that you know occur frequently
look for volunteers, use short cycles of change, fix one thing at a
time
 Root Cause Analysis: Action
Set reasonable/attainable goals
Link goals to measurement
Choose an action that fits the root cause
Avoid outcomes like training, writing a policy, pay
more attention
Instead pick a stronger approach such as
standardize, checklist, Equipment fix, Timeline for
multiple actions
Make changes that have the highest potential impact
facility-wide but test changes in one area first
Assign who, as well as when
 Root Cause Analysis
Resident Reports Pain
While passing her in the hallway a new
Certified Nursing Assistant told the Charge
Nurse that a resident was complaining of pain.
During orientation the CNA was told to always
inform the Charge Nurse of resident changes
that could indicate pain. The Charge Nurse is
an agency nurse who is currently working a
double and replied to the CNA, She just wants
attention. I dont think she is really in pain. and
kept walking down the hall.
 Root Cause Analysis
Resident Reports Pain
Was communication from the CNA adequate?
Was the CNA oriented to the pain
management program?
Was the Charge Nurse following the policy
and procedure and standards of care?
Reason?
FISHBONE DIAGRAM: GROUPINGS

Policies People

Environment Equipment/Supplies
 Root Cause Analysis
Fishbone Diagram: People

Lets look at the nurse and CNA

Fatigue (short staffing, personal problems)
Communication (lack of information regarding the
process)
Training (lack of orientation or ongoing training,
lack of competency checks)
Lack of supervision
Other
 Root Cause Analysis
Fishbone Diagram: Policies &Procedures
Procedures/ Rules/Policies
No written policy and procedure
Failure to follow the policy/procedure
Standards of practice not known
Standards of practice not followed
Lack of supervision to assure process is followed
Lack of orientation or information regarding the
process and/or resident needs
Other
 Root Cause Analysis
Fishbone : Environment & Equipment
Using the fishbone diagram
Equipment/Environment (examples)
Medication for pain hard to obtain - locked away
from medication cart
Furniture not comfortable resulting in
exacerbation of pain
Improper restraint leading to immobility and pain
Inadequate supplies for positioning
Assistive equipment not fitted for resident,
causing pain
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?

Act Plan

Study Do
 The PDSA Cycle
for Learning and
Improvement What changes Objective
are to be made? Questions and
Next cycle? predictions (why)
Plan to carry out
the cycle (who,
what, where, when)

Complete the
Carry out the plan
analysis of the data
Compare data to Document problems
predictions and unexpected
Summarize observations
what Begin analysis
was learned of the data
 Root Cause Analysis Tips (continued)

Participation of leadership of the organization

is important
Participation of individuals most closely
involved is necessary
Cannot be contradictory
Doesnt leave obvious questions unanswered
 Root Cause Analysis
Summary
Look at all information.
Investigate thoroughly
Use the Fishbone Diagram
Propose many solutions.
Look at the process
Pick one intervention for testing in a small area
(PDSA)
76 yo with burns
Harry Owens, a former a landscaper, is 76 yo widower and resident at Rolling
Meadows NH, has Alzheimers. He helps with the flowerboxes on the unit. Harry
has two sons and a daughter. The boys live out of state and his daughter
Catherine visits after work.
Harry is oriented to self and recognizes familiar faces. Although, Harry uses a w/c
to wheel himself throughout the unit, he is often found in the kitchen snacking or
rummaging through closets. He has a snap-on belt on his wheelchair, which he can
not self release for safety and positioning. He c/o about the belt every time it is put
into place. He attempts to get out of the wheelchair to ambulate on his own if hes
not belted in. Last wk the housekeeper found Harry twice rummaging through
other residents personal closets and personal belongings.
He was found by the housekeeper lying on the floor in another residents room
with burns to his chest and arms. A partially burned snap-on belt was attached to
his wheelchair. He was last seen in front of the nurses station waving to a CNA who
was returning from her break to have a cigarette.
He was sent to the hospital where they diagnosed Harry as having 3 rd degree burns
to his chest and arms.
With your team consider the following questions:

1. When during the day is the person at risk?

2. What is the best treatment and what are your strategies for
accomplishing it?
3. What are the potential barriers to that treatment?
a. What conflicts are there between treatment protocols and the individuals
patterns or rhythms?
b. How can these conflicts be reconciled to achieve the best outcomes
c. What conflicts exist between the treatment protocols and the institutional
pressures (i.e. Schedules, other departments needs)
d. How can you reconcile these to support your care?
4. Look at the HATCh model. In each of the domains what is needed to
care for this individual?
HATCh: Holistic Approach to Transformational Change

Environment Care
practices

Workplace
practices
 Were flower
The analysis (1/3) boxes easily
accessible?

Where activities
scheduled at this
time?

Resident on Resident is a fall Snap-on belt Snap-on belt

independently risk according to used to maintain used to maintain
wheeling self on fall assessment position in position in
unit wheelchair? wheelchair?

Did staff receive Are other

training for the restraint
restraint and alternatives
facility available?
protocols?

Resident
complains about
the snap-on belt
 CNA left cigarette
lighter at the
Analysis (2/3) nurses station

How was the

ignition source
obtained?

Why was this

restraint device
used? What was the
ignition source?

Resident falls out of

Resident is wearing a Snap-on belt ignites his wheelchair
snap-on belt and breaks

Staff member called

Was a reduction Was the resident in sick
ever put into a known fire
place? risk?

Why is snap-on Short staffed. When

belt returning from break
combustible? CNA was called to assist
co-worker
 Analysis (3/3)

Resident not seen for

15 minutes

Short staffed. Resident Snap-on belt Resident Resident

Staff member When used lighter breaks and found treated and
called in sick returning that CNA left resident slips burnt, lying transferred
from break at nurses out on the floor to the local
CNA was station burn unit
called to
assist co-
worker
 Esther: 77 yo post hip pinning

EXERCISE: Esther is a 77-year-old widowed F, living independently at

home. Her daughter lives close by and visits frequently. 6 d ago, Esther Fx
R hip from a fall at home. At the hospital, hip was pinned. Since her
admission to the SNF 2d ago, she c/o significant postop pain for which she
has a prn pain medication scheduled. PT and OT were ordered but Esther
refused therapy stating, she was not ready to move too much. The
therapy director has mentioned to the DON that her physician should be
called because it is getting difficult to justify Medicare coverage. She stays
perfectly still for long periods of time with her eyes closed. Her preferred
position is supine with the head of the bed elevated and a pillow under the
affected right leg. She rings the call light frequently for the bedpan and for
pain medication. She is eating small amounts of a soft diet.
With your team consider the following questions

1. When during the day is the person at risk?

2. What is the best treatment and what are your strategies for
accomplishing it?
3. What are the potential barriers to that treatment?
a. What conflicts are there between treatment protocols and the individuals
patterns or rhythms?
b. How can these conflicts be reconciled to achieve the best outcomes
c. What conflicts exist between the treatment protocols and the institutional
pressures (i.e. Schedules, other departments needs)
d. How can you reconcile these to support your care?
4. Look at the HATCh model. In each of the domains what is needed to
care for this individual?
95 yo with pressure sore
Aunt Sharlie is 95 yo with a h/o CAD, DM and severe PVD. She weighs 98
lbs, is 50 tall and has dementia. Aunt Sharlie scoots around the facility in
her wheelchair using her L foot to propel herself. She can stand and take a
few steps.
When staff attempt to reposition her she refuses and says Leave me
alone, will ya? She eats small amounts of finger foods, spits out most of
her pills, and is hard to slow down because of her activity level. Prior to
her residence at the nursing home she was an avid gardener and enjoyed
walks in the park.
She developed a pressure ulcer on the right heel last summer, which
resulted in an above-the-knee amputation in November. During this time
she also developed a stage III pressure ulcer measuring 4x3x2 at the
coccyx. The pressure ulcer has healed, but she is still at high risk. A Foley
catheter is being used to manage incontinence and keep the coccyx dry.
With your team consider the following questions:
1. When during the day is the person at risk?
2. What is the best treatment and what are your strategies for
accomplishing it?
3. What are the potential barriers to that treatment?
a. What conflicts are there between treatment protocols and the individuals
patterns or rhythms?
b. How can these conflicts be reconciled to achieve the best outcomes
c. What conflicts exist between the treatment protocols and the institutional
pressures (i.e. Schedules, other departments needs)
d. How can you reconcile these to support your care?
4. Look at the HATCh model. In each of the domains what is needed to
care for this individual?
88yo F with Adverse drug event
An 88 yo F with dementia, a HTN, and CAD s/p CABG went from NH to ED
for worsening confusion. She had been in hospital 6 wks ago for urosepsis, and
allergy to levofloxacin was noted.
Initial evaluation revealed leukocytosis and pyuria, but no fever or flank pain.
The ED MD concluded that a UTI was the most likely cause of the altered
mental status, and prescribed levofloxacin.
The first dose was given on the medical floor shortly after the patient arrived.
Over the next 6h, patient became increasingly agitated and required sedation
and restraint. She developed a diffuse erythematous rash across the chest and
back, swollen lips and tongue, and audible wheezes; ? anaphylactic reaction!
In the ICU she was treated with IV steroids, antihistamine, and inhaled beta
agonists. The levofloxacin was changed to an intravenous cephalosporin.
After the event, the patients paper chart was brought to the ICU from the Medical
Records Department. The D/C summary from last admission reported an allergic
reaction to levofloxacin. Her daughter, arriving later that evening, was exasperated
to learn of her mothers condition. She said, Youre supposed to help her get
better, not worse!
Questions

Should the nursing home physician confer with the Emergency

Department physician at the time of ED evaluation?
Should a demented patient wear a medical alert wristband?
Is there a trade-off between clinicians attempts to provide timely care
such as rapid administration of antibiotics and other treatments
and safety?
Interviews

The Emergency Department Physician

I saw the patient and requested her records. I thought about treating her
UTI with a cephalosporin, but the nurse told me the patient had very
thin veins and tenuous IV access. I thought a quinolone made sense
because you can take it orally. I reviewed the transfer sheets from the
nursing home record and saw no note of an allergy. Unfortunately the
patient was too sick to tell me about her allergies. I wish Id waited for
the chart to come up from Medical Records, but there was a trauma
case coming in and we needed the bed.
The floor nurse
It was a busy day. We had 4 admissions all at once. I settled the pt and
went on to help the other nurses. I administered all my pts meds, but I
didnt get a chance to sit down and do my paperwork until the end of
the shift. I then remembered hearing about the pts last admission and
recalled there was an allergy to levofloxacin. But by then, she was
already wheezing and swollen. We all rely on the doctors and
pharmacists too much to get the order right.
Interviews
The pharmacist
What a catastrophe! I remember receiving the order for levofloxacin. The
pharmacy computer showed that the patient had no known drug allergies. We
dispensed the drug and sent it up to the floor. Although the pharmacy computer
keeps a record of every drug allergy that is brought to our attention, there is no
consistent way that the information gets to us. If it is written in an admission
note or discharge summary but not on the physician order sheet, there is no
way we would learn of the allergy. We do the best we can, but we need some
help from the clinicians.

The daughter
I am beyond exasperated. I know that things are busy and that the doctors and
nurses here try to do the right thing, but they ought to know better than to give
my mother a medicine shes allergic to. If you cant get a simple thing like that
right, how can patients expect that youll get it right when you do something
complicated? Whats so hard about saving allergy information in a single place
so everyone can find it? I know all about my mothers allergies and
medications. Why couldnt somebody give me a call?
What Happened? Why did this happen? Risk Reduction Strategy
Proximate Cause Contributing Factors Action Plan
ED physician Medical record did not arrive in timely 1. Pharmacy reviews discharge
prescribed drug to way summaries for allergy
which patient was Nursing home data was incomplete information
allergic
Workload and trauma case distracted Increase staff resources in the
MDs attention Emergency Dept.
MD assumed pharmacy would double- Secure urgent access to
check order medical records for patients in
MD failed to call nursing home MD or the ED
family to confirm allergies
Patient unable to answer questions Provide patients with allergy
about medical history information wrist bands

Pharmacy dispensed Allergy not documented in the Educate staff

medication to which pharmacy computer during previous Centralize and integrate a
patient was allergic admission single electronic medical
record
Nurse administered Nurse unable to check records until Address staffi ng and workload
drug to which patient late in day because of workload issues
was allergic
 80 yo M with pressure sore
Charlie is an 80-year-old retired police officer, admitted to Happy Hills NH a few
months ago with L hip fx, NIDDM, dementia, and peripheral neuropathy. He is 5, 9
and weighs 146 lbs, alert and pleasantly confused. Ambulation is poor. He sits in a
straight back chair most of the day. Occ. he wanders on the unit looking for his patrol
car and top-secret documents (an elopement risk!). Upon admission the nursing staff
immediately initiated a plan of care to prevent the development of a pressure ulcer,
including placement of an air mattress on his bed and a cushion in his chair. He has a
sacral Stage II, although its improved some, and measured at 6 x 5cmx0.5 this
morning. Staff has been asked to place him in bed for an hour in the late morning and
then again late afternoon to relieve pressure. He is continent of urine on occasion and
staff state His brief is always heavily soaked with urine when we change him q 2h
Last week Charlie became more confused and his food intake lessened. Staff noticed a
blister on his L heel, possibly caused by his poor fitting shoes when he does wander in
the hall in pursuit of crooks.The nurse promptly notified the residents daughter
and MD of the blister, as well and the residents overall health decline. MD ordered
dietary supplements, a foam foot elevator while in bed, and an Rx for the blister. He
continued to lose weight, and blood sugars are now unstable, and his L heel blister
worsened to the where the nurses described it in their documentation as a stage II PU
draining large amounts of foul smelling exudate.
With your team consider the following questions:
1. When during the day is the person at risk?
2. What is the best treatment and what are your strategies for
accomplishing it?
3. What are the potential barriers to that treatment?
a. What conflicts are there between treatment protocols and the individuals
patterns or rhythms?
b. How can these conflicts be reconciled to achieve the best outcomes
c. What conflicts exist between the treatment protocols and the institutional
pressures (i.e. Schedules, other departments needs)
d. How can you reconcile these to support your care?
4. Look at the HATCh model. In each of the domains what is needed to
care for this individual?
Stefan Gravenstein, MD, MPH, CMD
Clinical Director
401-528-3200
sgravenstein@qualitypartnersri.org