Now that you have learned how to conduct a Root Cause Analysis (RCA), please perform one for the following scenario in your role as Quality Director for a 300 bed Nursing Home in Manhattan:
Mr. Caring, a Nursing Home patient was identified at risk for elopement
They were given a wanderguard bracelet, which is connected to the front and stairwell doors
Resident has been at facility for 15 years, is alert and oriented x 2-3, smoker, walks a small amount of feet and usually sits in a wheelchair, which they propel.
The resident is on 30 minute safety checks
At 7:00 am on Monday, you are at the facility and informed that Mr. Caring’s empty wheelchair ws found at the back door a few minutes prior.
Next steps…. do your root cause analysis to find out what happened and when you do, develop a corrective action plan tp prevent it from happening again.
There are different RCA formats available. Explore the templates and select one you are comfortable with. JCAHO has a very comprehensive template available..
links and video:
https://www.ahrq.gov/patient-safety/about/concepts-of-patient-safety.html
https://www.ihi.org/Topics/PatientSafety/Pages/GettingStarted.aspx
https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0197
https://www.sixsigmadaily.com/cause-and-effect-diagram/
