● To be effective, the analysis must establish all known pieces of the puzzle between the root cause(s) and the actual problem(s). ● Root cause analysis transforms an old culture that reacts to problems to a new culture that solves problems before they escalate, creating a focus on variability reduction and risk avoidance. Applying the process of RCA When people discover problems, the most frequent response is to rush to find a solution. Finding an immediate fix to a problem may be very satisfying for the moment but is not a long-term effective decision. The purpose and goal of applying RCA to medical errors that occur or that might occur is to find effective solutions rather than only discovering root causes. Root causes are secondary to the goal of prevention and are only revealed after deciding which solutions to implement. 1. Define the problem . The therapist can ask the following questions: What does the medical facility want to prevent? When and where did it occur? What is the significance of the problem? Is it possible to close the gap between patient safety and the accurate or effective process that defines the problem? 2. Gather data/evidence . This part of the process requires a collection, or a sample of data related to the problem. This will assist in conducting a root cause analysis to identify the reasons why the problem exists. Gathering data and evidence will form the basis for determining solutions to prevent a recurrence of the causes and ultimately lead to preventing the problem in the future. 3. Identify the fundamental relationships associated with the defined problem . The most common element of RCA methods includes asking why the error occurred, Costs of medical errors Medical errors carry a high financial cost. The IOM estimated that 400,000 preventable adverse events occurring in the hospital cost the nation $37.6 billion each year—including about $17 billion associated with preventable errors. The extra medical costs of treating only drug-related injuries occurring in hospitals alone conservatively amount to $3.5 billion a year (Van Den Bos et al., 2011). This includes 800,000 in long-term care settings, and roughly 530,000 occurring just among Medicare recipients in outpatient clinics. This estimate does not take into account lost wages and productivity or additional healthcare costs. About half of the expenditures for preventable medical errors are for direct healthcare costs. Like the physical and emotional harm caused by medical errors, the financial consequences do not stop at the hospital door. Hospital costs Studies that focus only on medical errors occurring during the initial hospital stay may underestimate the financial impact of patient safety events by up to 30%. These additional costs are for surgery patients who experienced the following medical errors compared with those who did not experience a medical error scenario, as reported by Relias Media (2008, n.p): ● “33% more for nursing care associated with medical errors, including pressure ulcers and hip fractures— ($12,196). Advancing patient safety requires a shift from reactive, piecemeal interventions to a total systems approach to safety in which safety is systematic and is uniformly applied across the total process (Rodziewicz et al., 2023). A total systems approach would require a prioritization of a safety
recording the answers and considering the possible cause behind each of these answers. RCA attempts to identify contributing factors and all causes, proceeding until the desired goal of finding the “root” cause is reached. 4. Identify which causes, when removed or changed, will prevent recurrence . Finding root causes will lead to the next step of evaluating the best method to change the root cause. This will allow for developing a more efficient procedure to put in place. This is commonly known as corrective and preventive action. 5. Identify effective solutions . An effective solution is one that prevents recurrence, is within one’s control, meets the goals and objectives which have been set forth, and does not cause other problems. 6. Implement and observe the recommendations . When the recommendations are implemented and subsequently observed for a period of time, it will become more obvious what the real solutions are to ensure effectiveness (Singh et al., 2023). Failure mode and effects analysis The Institute for Healthcare Improvement states that a Failure Mode and Effects Analysis (FMEA) is a “systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change (IHI, n.d.). FMEA was originally developed outside of healthcare by reliability engineers in the late 1950s to study problems that might arise from malfunctions of military systems. However, today FMEA is utilized within healthcare as a way to assess risk of failure and harm in processes and to identify the most important areas for process improvements (IHI, n.d.). ● 32% more for metabolic problems associated with medical errors, including kidney failure or uncontrolled blood sugar—($11,797). ● 25% more for blood clots or other vascular or pulmonary problems associated with medical errors—($7,838). ● 6% more for wound opening associated with medical errors—($1,426).” Summarizing who is responsible for costs There has been a longstanding call for further analyses to help hospital leaders evaluate the costs associated with medical injuries—and put a price tag on clinical interventions that could help prevent adverse events in the first place. Mello et al. (2007) reported the following facts and figures: ● “A review of 14,732 medical records from 24 hospitals in 1992 uncovered 465 medical injuries, including 127 negligent injuries. ● On average, hospitals absorbed $238 of injury-related costs for every patient admitted that year. They externalized, or passed on, $1,775 in injury-related costs per admission. ● Among the 24 hospitals, malpractice premiums amounted to an average of $123 per patient” (p. 860).
PREVENTION OF MEDICAL ERRORS
culture by leadership throughout the healthcare continuum. It would mean addressing both the increased mortality and substantial morbidity that safety failures cause. Leadership would have to prioritize the well-being and safety of the healthcare workforce. System processes would need to
EliteLearning.com/Massage-Therapy
Book Code: MFL1227
Page 103
Powered by FlippingBook