Case Study 2 The following case demonstrates a root cause analysis that was conducted following a sentinel event, and it meets The Joint Commission’s criteria. Khemrin Chey is a 60-year-old widower who emigrated from Cambodia through a church-sponsored program. A former teacher, Mr. Chey lives with his married daughter and works as a janitor for the church. This afternoon, the pastor discovers Mr. Chey sobbing in the church basement and calls his daughter, who brings her father to the hospital emergency department. Lee, an interpreter who works at the hospital, assists Dr. Gordon, the psychiatric resident, as he evaluates Mr. Chey for admission. Mr. Chey’s daughter provides recent history, reporting that her father has refused to eat for the past two weeks and has slept less than three hours a night during this time. Since his arrival in the U.S., Mr. Chey has repeatedly told his daughter that he desires to join his deceased wife. At this point in the interview, Dr. Gordon is paged to another emergency. He admits Mr. Chey to the psychiatric unit with a provisional diagnosis of major depressive disorder, places him on periodic suicide watch, and promises to return that evening to complete his assessment. To eliminate any possibility of miscommunication, Lee, the interpreter, explains all of this to both Mr. Chey and his daughter. In response, Mr. Chey asks one question: Will he be allowed to pray in his room? Lee answers yes, and then receives a call that he is needed in another part of the hospital. On his way, Lee places a call to Amy, the social worker, and leaves a voicemail message, asking that she call him about Mr. Chey and requesting that she convene a family session the day after tomorrow, which is when he is next scheduled to work at the hospital. Jenn, a nurse, and Elise, a nursing assistant, are working the evening shift. They agree to share responsibility for monitoring Mr. Chey’s suicide watch and decide to check on him at five- minute intervals. With Mr. Chey’s admission, the unit is at full capacity, and he is given the only vacant room, at the far end of the corridor. Each time Jenn or Elise pass his open door, they find Mr. Chey kneeling at his bed, head bowed. And each time, he turns, acknowledges them with a nod and a smile, and turns back to pray. When Jenn returns to the nursing station after distributing the evening medications, she asks Elise when she last checked on Mr. Chey. Elise responds with a surprised look and says that she assumed that Jenn would be checking on him as she passed out medications. They race to Mr. Chey’s room together and find him hanging from a bedsheet attached to the back of the door. Mr. Chey’s suicide meets The Joint Commission’s criteria of a sentinel event (the suicide of any patient receiving care, treatment, and services in a staffed, around-the-clock care setting or within 72 hours of discharge), and a root cause analysis is scheduled five days after his death (The Joint Commission, 2022a). Two employees from the Quality Improvement Department, a facilitator and a scribe, arrive at the unit conference room 15 minutes early to prepare for the session. They post large sheets of white paper around the room, labeling each sheet with a different heading: Physical Causes, Environment, Human Factors, Communication, Staffing, and Policies. These particular labels emerged from findings in root cause analyses conducted in other parts of the hospital; the categories are flexible and can be refined as needed. This is the first time that a root cause analysis will be conducted on the psychiatric unit, and the facilitator and scribe wonder if the categories will be applicable in a behavioral setting. As the facilitator watches the participants settle in the conference room—Jenn (nurse) and Elise (nursing assistant), Lee (interpreter), Amy (social worker), Dr. Gordon (psychiatric resident), and Terry (head nurse)—she notices that everyone seems nervous. After introductions, the facilitator asks if anyone has participated in a root cause analysis process before, and all
the participants shake their heads no. Jenn, the nurse, however, has heard about the process from another nurse who works in neurosurgery, and her friend reported that the experience had been positive. The facilitator explains that root cause analysis is a process designed to uncover flaws in the system. Despite the system focus, she cautions the participants that they will likely feel an urge to blame, and that this is a natural human tendency whenever a tragedy occurs. She goes on, saying that in guiding the root cause analysis session, if she hears any attempt to place blame, it is her responsibility to redirect the conversation, moving it back to a focus on the system. The facilitator continues, saying that, together, the participants will consider all possibilities to seek a root cause or causes. She will follow prompts suggested by The Joint Commission (The Joint Commission, 2022a), and for each finding that emerges, she will ask “Why?” and drill down to uncover the reasons that parts of the process did not happen when they should have. She will continue to dig deeper until no additional logical answers can be identified. The scribe will document the discussion by writing findings on the sheets on the wall. Participants will determine, with the facilitator’s guidance, which category is most appropriate for each finding; new categories will be added if needed. Another template is also displayed in the room as a visual aide (see Figure 2). The formal name for this template is an Ishikawa diagram, and it is also called a fishbone or cause-and-effect diagram. The labels on the template match the headings on the wall sheets, and after the session, the scribe will enter the information onto the cause-and-effect template in the order in which it was received from participants. When completed, the scribe will send a copy to each of the participants so that they can verify its accuracy. The facilitator prompts the discussion by asking what guidelines were in place regarding the assessment of suicidal patients at the time of Mr. Chey’s death. Dr. Gordon answers that the department of psychiatry’s policy is for residents to complete a psychiatric evaluation within six hours of admission. Since Mr. Chey’s death occurred within three hours of admission, the department’s guidelines were followed. The facilitator then asks about human factors (human performance factors that may have contributed to the event), environmental factors, staffing levels, communication, and the physical environment. The staff members discuss each of these factors, and the following information is written on wall sheets. ● Physical causes (physical objects, including machinery and equipment): Although staff had removed Mr. Chey’s belt and shoes, the bedsheets remained in the patient’s room. ● Environment (staffing, time of day, and acuity/census): Dr. Gordon was paged to the emergency department before he completed his assessment of Mr. Chey. The unit was at full capacity; Mr. Chey was assigned to a room that was far from the nurses’ station. There was only one registered nurse and one nursing assistant attending to the needs of 25 patients. The suicide occurred during the busiest time of day, when meals and medications were being distributed. ● Human factors ( distraction, fatigue, failure to follow a specified protocol): Nursing staff members were distracted by other duties; there was no clear assignment of responsibility for individual monitoring (diffusion of responsibility); the psychiatrist did not administer a structured suicide assessment during the admission evaluation. ● Communication: During the root cause analysis, Lee (interpreter) shared additional information that he had planned to discuss with Amy (social worker): (1) Mr. Chey was a proud man who had emigrated only because of pressure from his daughter and (2) nursing staff was pronouncing his name incorrectly.
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Book Code: PYFL4024
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