Root Cause Analysis

Abstract

In the summer of 2020, a patient at a major Veteran Affairs medical center in the western United States experienced an unwitnessed fall in their telemetry patient ward. This incident resulted in the patient receiving a fracture in his/her C5 cervical spine area. This eventually led to his/her death the following day. After determining a Safety Assessment Code score of 3, the patient safety manager determined that an immediate root cause analysis (RCA) was required. After assembling an interdisciplinary team and providing training on the VA's RCA policies and processes, an initial timeline of the sequence of the events was created. After identifying the gaps, personnel were interviewed, and using triage questions, the full flow diagram of the incident was created. By understanding what had occurred, the team was able to find the root causes of key events within the timeline. Four root causes were determined. One was the lack of an immobilization protocol for patients who sustained injuries from a fall. The second was the misinterpretation of the restraint policy by the nursing staff. The third was failing to identify risk factors associated with a patient's Morse fall risk score. Finally, the last root cause was the improper patient bed configuration of using a mattress from a different vendor. All these root causes received action plans that seek to reduce future problems from occurring. Although I had limited time with the overall RCA project, I learned a lot about the VA process and how important and valuable a good RCA is in preventing issues from occurring again and ensuring patient safety is held to the highest priority for a hospital and healthcare system.