Root Cause Analysis In Nursing

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Have you ever been a situation whereby an elderly patient with high fall risk was left alone in a toilet? Elderly tend to be more fragile and are prone to serious injuries when they fall. (Hill & Fauerbach, n.d.). In hospital wards, nurses do the best measurements to ensure zero falls, maintain a clean record and raise awareness to prevent falls.

It was an incident that happened during one of my clinical placement in September. Accompanied by a student nurse, a male elderly patient with high fall risk was unable to control his bowel movement and unintentionally made a mess along the toilet corridor. I helped to inform
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Root cause analysis is an approach to problem interpretation to identify the fundamental cause of an issue that happened (Cerniglia-Lowensen, 2015). (Lee et al, 2012) stated that the whole root cause analysis process includes three vital components which are “what”, “why” and “how” to curb the situation and root cause analysis is usually used in conditions whereby major injury or death happens or in situations that are barely avoided. Applying to my case, my patient had a high chance of falling which can lead to unforeseeable circumstances. (Lee et al, 2012) also mentioned the four stages of effective root cause analysis which is step one, recognising the issue which includes a thorough non-sentimental charged meaning of the process. Step two, detailed collection of information, information collected must come from various origins depending on the actual incident including staffs who witnessed the incident. Step three of the root cause analysis recognises the reasons that may have emerged in the sentinel event. It includes reviewing the order of events that became the issue, the factors that caused the issue to escalate, and considers as many recognised reasons as possible. At step four of the root cause analysis, advices and applications are included in the data garnered by using the root cause analysis to rule out future problems. Applying the four steps to my case, firstly, I will recognise the issue which is patient’s fall risk. At second stage, I will collect information from the enrolled nurse, staff nurse and student nurses who were present.

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