Root-Cause Analysis and Safety Improvement Plan | NURS-FPX4020

Running Head: Root Cause Analysis 1
Root-Cause Analysis and Safety Improvement Plan
YOUR NAME
NURS-FPX4020
Capella University
Month, Year

Root Cause Analysis 2
Root Cause Analysis
The sentinel event involves John, a 38-year-old patient who was scheduled to have
transbronchial biopsy of the upper right lung to acquire specimens that would help conclude
whether his lung had been infected. He had consented to a bronchoscopy using fluoroscopic
guidance. However, the procedure was undertaken on the wrong lung. The paper, therefore,
seeks to find the fundamental causes that led to this error in the scenario.
Analysis of the Root Cause
The bronchoscopy was planned to be the opening procedure of the day. However, the
procedure was postponed because the operating room was in use during that time. As a result of
the delay, the nurse had a lot of cases piled up and hence completed the preoperative evaluation
in a hurry.
The C-arm and the laterality of procedural images were set up by the circulating nurse
because the diagnostic radiology technician (DRT) assisted with the completion of another
procedure in the next room. The laterality of the images was noted to be correct. However, this
was not confirmed during the time out process because the operation did not address laterality.
The pulmonologist inserted the scope of the left lung to obtain biopsy specimens. The DRT
entered the endoscopy room to help with fluoroscopy. The DRT did not notice any errors when

Root Cause Analysis 3
the pulmonologist noted the completion of the left lung specimen collection because the images
aligned with the location that the pulmonologist had communicated. Since nobody else was
concerned about this he assumed it was correct. Since everyone had a specific task in the
procedure the error was not noticed because each assumed that everyone had performed their
tasks excellently including themselves.
However, during the probe after the procedure, the diagnostic radiology technician
decided to voice his earlier concern that the wrong lung had been operated on. Fortunately, the
procedure did not have any high-risk effect on the patient because it was only the retrieval of
specimens for examination. However, the team had wasted precious time and resources operating
in the wrong area. The examination was conducted on the right lung after readjusting the patient
correctly.
Improvement Plan with Evidence-Based and Best-Practice Strategies
The adoption of the universal protocol for preventing wrong-site surgery was not
followed for this procedure. The most important strategy was to ensure that the correct surgical
site was identified and correctly marked on the patient. This should also be ensured by a pair of
clinicians involved in the procedure (Kung, Brook and Slanetz, 2016). The validation of this
information should be preferably done the night before the procedure to prevent any last-minute
rushes and panicking. It would also ensure that the patient has a chance for the patient to confirm
the details of the surgery.
The main priority of the clinic was to ensure that it develops a compulsory protocol.
Implementation of the protocol would ensure that the correct site for surgery is identified and
verified. This should be a collaborative effort for all staff members who include but are not