HC 405: Root Cause Analysis of Sentinel Event in Healthcare Org

This report presents a root cause analysis of a sentinel event within a healthcare organization, employing the cause and effect fishbone diagram to identify the underlying factors contributing to the incident. The analysis focuses on a community hospital wing specializing in women's delivery, where a doctor's error in judgment, coupled with communication breakdowns among staff and the unavailability of emergency equipment, led to a patient's death. The fishbone diagram highlights issues such as a malfunctioning lift, the distance to the operation wing, and the lack of emergency settings on the second floor as contributing causes. The report concludes that the analysis effectively identifies various causes leading to the sentinel event, emphasizing the importance of preventing future occurrences through better structuring and addressing hidden issues within the organization. The root cause analysis helps in identifying the active and hidden errors within an organization by collecting relevant data through interviews and reviewing existing records, providing a structured approach to understanding and mitigating risks in healthcare settings. Desklib provides similar solved assignments.

Running head: HEALTHCARE MANAGEMENT
Healthcare management
Name of the student
Name of the university
Author note

1HEALTHCARE MANAGEMENT
Introduction
This is a report, which depicts the root cause analysis of a health care organization
where a sentinel event has occurred. The cause and effect fishbone diagram has been used to
identify the causes for this incident. The analyses of severe incident in done through a
structured method, which is known as the root cause analysis. Root cause analysis is a tool
for the analysis of the error and it helps to identify the fundamental problems in an
organization. The root cause analysis is an effective method of the identification of errors
done by the individuals in an organization. The root cause analysis not only identifies the
active errors in an organization but also at the same time identifies the hidden errors within an
organization. Root cause analysis collects all the relevant data and constructs it into effective
way by conducting interviews and reviewing the existing records.
Fishbone Analysis
Fishbone analysis is one of the methods, which is used in quality management to
identify the main causes for occurrence of an event (Izudi et al., 2017). The diagram portrays
the causes and the effects of a problem; this can be considered as a tool for visualization and
can be used to identify the major factors. This diagram is also known as Ishikawa diagram
(Jingxia et al., 2014).
Environment
Policy and Procedure People
Lift not working
properly
Distance of the
operation wing
Error in
judgement

2HEALTHCARE MANAGEMENT
The above fishbone analysis shows the exact causes that has caused the death of the
patient. The community hospital wing specialises in the delivery of women and the doctor
made an error of judgement (Latino, Latino & Latino, 2016). She already had the idea that
operation theatre was in the third floor the hospital and it will take more time than the
expected to reach there. The staffs were aware of the fact that the lift will take more time and
the condition of the patient may deteriorate within that time period. There should have been
better communication among the staffs; the lack of communication between them caused
them to take more time than the expected to reach the operation wing (Abdi & Ravaghi,
2017). There are certain cases where emergency equipments are required but there are no
availability of equipments for the contingencies.
Conclusion
Thus, after the evaluation of the fishbone analysis the report is able to identify the
various causes, which has lead to the sentinel incident. The death of a patient is a serious
issue and so it is necessary for the hospital authorities to identify the causes for the incident
so that the hospital can prevent further events like this. This analysis will help the
organization to prevent such incidents in the future and help in better structuring of the
organization. There are various hidden issues that have not been identified earlier and with
the help of the root cause analysis, the hidden issues have been magnified.
Communication Equipment
Root cause analysis
Lack of
communication
among the staffs
Lack of emergency
setting on the second
floor
Death of
patient

3HEALTHCARE MANAGEMENT
Reference
Abdi, Z., & Ravaghi, H. (2017). Implementing root cause analysis in Iranian hospitals:
challenges and benefits. The International journal of health planning and
management, 32(2), 147-162.
Izudi, J., Epidu, C., Katawera, A., & Kekitiinwa, A. (2017). Quality Improvement
Interventions for Nutritional Assessment among Pregnant Mothers in Northeastern
Uganda. BioMed Research International, 2017.
Jingxia, L., Huani, P., Dan, L., & Li, G. (2014). Fishbone diagram reduces the incidence of
blood residual after sealing tube indwelling needle. Modern Clinical Nursing, 9, 020.
Latino, R. J., Latino, K. C., & Latino, M. A. (2016). Root cause analysis: improving
performance for bottom-line results. CRC press.