Root Cause Analysis: The Joint Commission (TJC)

Root Cause Analysis A root cause analysis is mandated by The Joint Commission (TJC) to be completed for every sentinel even. By doing this it allows healthcare providers to review contributing factors, establish a baseline and how to prevent future events from occurring. Root causes are identified factors within a process that can be restructured to decrease the risk of harm being repeated. (The Joint Commission, 2013) A sentinel event is defined by The Joint Commission as “unexpected occurrences involving death, or serious physical or psychological injury”. (The Joint Commission, 2013) The following events are the results of the root cause analysis done on this case study. These are the causative factors, errors and/or factors that had

• During conscious sedation policies were not followed properly. It is required to have vital signs, continuous pulse ox. and ECG monitoring. This needs to be done pre and post procedure.

• Post sedation procedures were not followed accurately.

• No interventions for post sedation were implemented for oxygen and vital signs below the normal limits.

• During conscious sedation respiratory therapy should have been notified and standing by, as well as evaluating the patient post sedation. They should have been notified of the low oxygen levels.

• The LPN and the nurse did not notify the MD that the patient’s vital signs and oxygen were low.

• The LPN reset alarms without notifying the nurse or the MD.

• No additional staff was called in to assist with the additional patient load to create a safer working environment.

• Nurse J who is BLS/ACLS certified did not start compressions immediately when the code was called. They waited for the code team to arrive.

Change

• Causes: Why did these failures occur?

• Effects: Once the failures occurred, what were the results of these failures?

Once the assessments are completed they are then given a numerical value also known as the Risk Priority Number (RPN). This number helps indicate the reoccurrence rate or the severity of the sentinel event. The RPN ranges in value from 1 to 1000, the higher the number the higher the severity. The higher the RPN the higher the priority it is given to address the changes. (Institute of Healthcare Improvement, 2004)

To summarize the steps of the FMEA in the case of Mr. B they are as follows (Institute of Healthcare Improvement, 2004):

1. Identify all the members involved in the interdisciplinary team.

2. Choose specific root causes that will be useful in the