NURS3002 Assessment 2: Root Cause Analysis Report - Sylvia Confos Case

This report presents a Root Cause Analysis (RCA) of a case involving an 87-year-old patient, Sylvia Confos, who died due to multiple comorbidities, primarily a sacral ulcer, along with bacterial septicaemia, cortical atrophy, and other health issues. Using the Flipkart checklist method, the report identifies contributing factors such as poor nutrition, ineffective communication, and inadequate care related to pressure ulcer prevention. The RCA highlights the importance of interventions, including pressure reduction, wound care, infection control, and addressing underlying conditions like depression and high blood pressure. The report emphasizes evidence-based practices, such as balanced diets, blood tests, and psychotherapies, to improve patient outcomes and prevent similar incidents. It concludes that comprehensive care, addressing both the physical and psychological needs of patients, is crucial in managing complex health conditions and preventing adverse outcomes.

NURS3002 ASSESSMENT 2 Outline Report: Root Cause Analysis
(RCA)
Please follow instruction as per original brief.
See red and green areas.
Limit the use of the word ‘THE’ it is being used for no reason to fill words. About 20
‘THE’ have been removed.
Report is about a sacral ulcer, this is hardly mentioned

INTRODUCTION
The Root Cause Analysis (RCA) is basically a process in which the root causes of the
problems are discovered for identifying the appropriate solutions. RCAproves to be effective in
systematically preventing and solving for the underlying issues (Kellogg and et.al., 2017).
Various techniques, methodologies and principles are used for identifying the root causes of any
event or incident. The main goal of the root cause analysis is discovering the root cause of any
event or problem, the secondary goal is fixing, compensating and learning from the issues of the
root cause and the third goals is applying the learning of the analysis in systematically preventing
the issues in future (Solé et.al., 2017). This report will shed light on various steps in life of Sylvia
Confos who died due to numerous co-morbidities including sacral ulcer and various natural
causes. The checklists Flipkart will be used as main method as it will help in covering all aspects
of incident. The major cause of death was found to be sacral ulcer which will be majorly
highlighted. Various interventions will be described for resolving issues which were faced by
Sylvia Confos. These can be faced by the patients in future due to the diseases like sacral ulcer,
bacterial septicaemia, cortical atrophy and other issues due to high cholesterol, high blood
pressure, depression and dementia.
Root Cause Analysis (350 words = Description + Table)
Sylvia Confoswas an 87 year old resident in CastellorizianAged Care Facility in
Kensington, Sydney. The two fold process can be used for identifying and analysing the root
cause which initiates from the flow diagram followed by the description of the causes or the
contributing factors.
The flow diagram for the Root Cause Analysis is as shown below which will highlight the major
as well as supporting causes which led to the death of the patient. The major cause of the death
of the patient was a sacral ulcer but the supporting causes include bacterial septicaemia along
with major co-morbidities such as atherosclerosis of the wills’ circle in the brain and cortical
atrophy (Zhong and et.al. 2020). Not only this, the patient was also suffering from high blood
pressure, depression and high cholesterol. But when she died the main cause of death was found
to be the sacral ulcer. Sacral ulcer is also known as bedsores or decubitus ulcers. These are the
skin injuries which are basically developed most commonly on the bony areas of the body. The
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sacral ulcer is considered as the most common type of injuries. The region of sacral is the area
which is the lower back near the spine.
Flow diagram
Root causes/ Contributory factors Table
3

Item
No.
Description
of root
cause/contrib
utory factor
Category (as described in the Checklist Flip Chart for Root Cause Analysis Teams)
Communica
tion
Knowledge,
skills and
competence
Work
environment/
scheduling
Patient
factors
Equipment Policies/
procedures
Safety
mechanisms
1 Not ensuring
good
nutrition.
❎ ❎ ✅ ❎ ✅ ❎ ✅
2 Ineffective
communicati
on between
the
practitioner
and patient.❎ ❎ ❎ ✅ ❎ ✅ ✅
3 Sweating
heavily and
incontinent
patients have
higher risk of
developing
the sacral
ulcers.❎ ❎ ✅ ❎ ✅ ❎
4

Item
No.
Description
of root
cause/contrib
utory factor
Category (as described in the Checklist Flip Chart for Root Cause Analysis Teams)
Communica
tion
Knowledge,
skills and
competence
Work
environment/
scheduling
Patient
factors
Equipment Policies/
procedures
Safety
mechanisms
4 The nurses
not ensuring
that the
person is
experiencing
shear and
friction.
Friction in
bony areas
like spine
contributes in
breakdown of
the skin.❎ ❎ ✅ ❎ ❎ ✅ ❎
5 Not washing
the area with
mild soap
and water
(Elkirami,
2017).
❎ ✅ ✅ ❎ ✅ ❎ ❎
5

Item
No.
Description
of root
cause/contrib
utory factor
Category (as described in the Checklist Flip Chart for Root Cause Analysis Teams)
Communica
tion
Knowledge,
skills and
competence
Work
environment/
scheduling
Patient
factors
Equipment Policies/
procedures
Safety
mechanisms
6 Sores when
not covered
with special
dressing
increases the
risks of the
disease and
make the
condition of
the patient
worse.❎ ✅ ✅ ✅ ❎ ✅ ❎
7 Using
products
which dry out
the skin.❎ ✅ ✅ ❎ ❎ ❎ ✅
8 The position
of the patient
kept same
and not
changed
regularly.❎ ✅ ❎ ❎ ✅ ❎ ✅
6

Item
No.
Description
of root
cause/contrib
utory factor
Category (as described in the Checklist Flip Chart for Root Cause Analysis Teams)
Communica
tion
Knowledge,
skills and
competence
Work
environment/
scheduling
Patient
factors
Equipment Policies/
procedures
Safety
mechanisms
9 Inappropriate
data on the
Antibiotics if
not given
rapidly to the
patient then it
can increase
the risks of
bacterial
septicaemia.
❎ ✅ ✅ ❎ ✅ ❎ ✅
10 Not
Understandin
g the severity
of the disease
bacterial
septicaemia
(Crutch and
et.al. 2017).❎ ❎ ✅ ✅ ❎ ❎ ✅
11 Not giving
proper
medications
for treating
cortical
atrophy,
depression
and anxiety.❎ ✅ ❎ ✅ ❎ ❎ ✅
7

Item
No.
Description
of root
cause/contrib
utory factor
Category (as described in the Checklist Flip Chart for Root Cause Analysis Teams)
Communica
tion
Knowledge,
skills and
competence
Work
environment/
scheduling
Patient
factors
Equipment Policies/
procedures
Safety
mechanisms
12 Taking the
symptoms of
the sepsis
lightly such
as fever,
chills, rapid
breathing and
confusion.❎ ❎ ✅ ✅ ❎ ✅ ❎
Potential Intervention
There are various interventions which can help in treating the severity of conditions such
as sacral ulcers so that in future no person dies due to a sacral ulcer and other co-morbidities.
These are also known as bed sores which mainly occur due to high pressure on the specific bony
areas of the body. Sacral ulcers occur because of the high pressure on the lower back near the
spine region (Tanaka and et.al. 2020). The treatment of sacral ulcers includes the reduction in the
pressure on the affected skin, controlling of the pain, caring for the wounds, preventing the
infection along with maintaining the good nutrition. This must be followed by cleaning and
dressing of the wounds. If the condition is more severe, then drugs must be taken such as
ibuprofen, naproxen sodium etc. If these do not work then surgery can be done. Furthermore, the
sacral ulcers can also be treated by performing the skin assessments in every 8 hours by making
use of Braden Scale. The nurse or the practitioner must also ensure that the position of the patient
is changed from left to right and to back after every 2 hours for offloading the pressure using a
wedge. The healing of the wound can also be done by ensuring adequate nutritional status along
with maintaining proper hydration. Another intervention for treating the sacral ulcer is to
motivate the patient to quit smoking and get involved in exercises which can be done on bed as
per doctor’s advice. The stress of the person must be managed and the patient needs not to be in
extreme stress. In order to cure the bacterial septicaemia, broad spectrum antibiotics must be
taken after getting the results of blood tests. This can help in improving the life-threatening
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infections. The secondary condition that contributed in the death of the patient was cortical
atrophy which could have been treated by medications which can also help in treating the
symptoms of depression and anxiety. Furthermore, the practitioners can also make use of the
occupational, physical and cognitive therapies which can help in regaining and retaining the
skills which are impacted by the posterior cortical atrophy (Arm and et.al. 2017). This is how
people suffering from conditions such as sacral ulcers and the co-morbidities mentioned
previously can be treated. This could improve the condition of the patient, and even save their
life. The sacral ulcer is treated by distant and local infections, maintenance of moist environment
for healing of wound, removal of necrotic tissue and at last stages surgery.
Evidence base for intervention
There are various resources which are needed for treating problems like sacral ulcers,
cortical atrophy, bacterial septicaemia, dementia, depression, high cholesterol and high blood
pressure. The effectiveness of the resources can help in improving the symptoms and can also
help in improving the quality of life of the patient. The main evidence for treating all these
disease is the consumption of the balanced diet (Moges and et.al. 2017). It must be ensured that
the weight of the patient does not increase rapidly. The diet must include all the important
nutrients and fibres instead of junk and oily food. Also, the practitioners must ensure that the diet
helps in the healing of the wound. This must include the intake of protein, vitamin A, E and C
and also the intake of amino acids such as glutamine and arginine (Moges and et.al. 2017).
Furthermore, another resource is the intake of water which helps in keeping the body hydrated
thereby leading to repairing of the skin. In case of bacterial septicaemia, blood tests must be
conducted for analysing the clotting problem, impaired availability of oxygen, evidence of
infection etc. Along with the blood tests being conducted, other lab tests must also be conducted
for identifying the source of infection such as wound secretions, urine or the respiratory
secretions. The other resources used are the x-rays, ultrasound, computerized tomography (CT)
and Magnetic resonance imaging (MRI). These help in identifying the infections in bones, soft
tissues, liver, pancreas, kidneys, gallbladder and many other abdominal organs (Arca-Contreras,
2021). In order to treat the other conditions such as depression, dementia, high blood pressure
and hypertension in the patient, antidepressants can help in relieving the symptoms in the older
people. But this can also cause side effects such as potential reactions with the other medicines
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so this must be effectively considered. Psychotherapies can also help in addressing the functional
and social consequences of depression (Ahmed and et.al. 2018). Also, various resources like a
peaceful and calm room, with a soothing view from inside where many people can be seen to
refresh the mood of the person must be arranged which can help in improving the symptoms of
the patient and she may not feel isolated and depressed. This can also help in maintaining the
blood pressure of the patient. These interventions are evidence-based as they are peer-reviewed
and documented empirical evidence of effectiveness. These use the various integrated strategies,
policies, activities and services which can be proved by research and evaluation. In order to cure
these issues, the evidence based practices and interventions can prove to be helpful. The
treatment of sacral ulcers can be done by particular ointment or dressing such as alginate
dressing or the hydrocolloid dressing. Also, this can be evident that the best way to heal the ulcer
is to clean it with salt water or water when the dressing is changed. The person who is at the risk
of getting the sacral ulcers must be placing the patient on a pressure reducing device such as
static air, foam, alternating gel air or water mattress. The treatment of the sacral ulcers is done
according to its severity. For example, if it is of stage 4, then the treatment can take almost 3-4
months. This is why, this must be treated at the earlier stage where it cannot lead to the death of
the person and can save one’s life.
CONCLUSION
It can be concluded from this report that various co-morbidities can contribute towards the
death of a patient. In the above report, Sylvia Confos was suffering from various issues such as
sacral ulcer, bacterial septicaemia, high cholesterol, high blood pressure and many others. The
major thing identified is that the person must take good nutrition and diet for improving the
condition prior to taking the medications. So, the report mainly used the Root Cause Analysis
which helped in analysing the main and the supporting causes which led to her death. The
method of the Checklist Flipkart was used which helped in identifying the various risk factors of
the different diseases she was suffering from. This method helped in analysing various aspects of
the root causes such as communication, patient factors, work environment, knowledge and skills,
equipment etc. This was followed by mentioning the interventions of the problems faced. Lastly,
the evidence of all the interventions were also highlighted and described. The main intervention
for treating the sacral ulcers is to keep the area clean and then do the dressing. Therefore, this can
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be concluded that if the patient is treated with the appropriate interventions then there are many
chances of the person to be cured otherwise the severity of the disease increases with time which
can lead to losing of life.
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REFERENCES
Books and Journals
Ahmed, S. & et.al. (2018). Association between presumes volume and autobiographical memory
impairment in posterior cortical atrophy: Beyond the visual syndrome. Neuro Image:
Clinical. 18. 822-834.
Amr, A. A. & et.al. (2017). A pre-post study evaluating the effectiveness of a new initiative, the
“PRESSURE bundle,” Compared with standard care in reducing the incidence and
prevalence of sacral pressure ulcers in critically Ill patients in an intensive care unit in
Riyadh, Saudi Arabia. Saudi Critical Care Journal. 1(3). 75.
Arca-Contreras, K. M. (2021). Flipping the Classroom to Optimize Clinical Decision-Making in
the Didactic Setting. Journal of Doctoral Nursing Practice.
Crutch, S. J. & et.al., (2017). Consensus classification of posterior cortical atrophy. Alzheimer's
& Dementia. 13(8). 870-884.
Elkirami, R. (2017). Using root-cause analysis for pressure ulcer prevention in a long-term care
facility (Doctoral dissertation, Utica College).
Kellogg, K. M. & et.al., (2017). Our current approach to root cause analysis: is it contributing to
our failure to improve patient safety?. BMJ quality & safety. 26(5). 381-387.
Moges, F. & et.al., (2017). Bacterial etiologic agents causing neonatal sepsis and associated risk
factors in Gondar, Northwest Ethiopia. BMC pediatrics. 17(1). 1-10.
Solé, M. & et.al., (2017). Survey on models and techniques for root-cause analysis. arXiv
preprint arXiv:1701.08546.
Tanaka, M. & et.al., (2020). The mechanism of persistent undermining of a sacral pressure ulcer:
experimental analyses using a deformable model and examination of skin mobility over
different anatomical locations. Journal of tissue viability. 29(2). 130-134.
Zhong, X. & et.al., (2020). Root cause analysis and diagnosis of solid oxide fuel cell system
oscillations based on data and topology-based model. Applied Energy. 267. 114968.
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