Capella University: Root Cause Analysis and Safety Improvement Plan

This report presents a root cause analysis of a sentinel event involving a wrong-site surgery, specifically a transbronchial biopsy performed on the wrong lung. The analysis delves into the factors contributing to this error, including procedural delays, rushed preoperative evaluations, and communication breakdowns among the surgical team. The report identifies the lack of adherence to the universal protocol for preventing wrong-site surgery as a critical factor. It then proposes an evidence-based safety improvement plan, emphasizing the importance of correct site marking, verification by multiple clinicians, patient involvement, and standardized time-out procedures. The plan also addresses organizational resources, such as system-based strategies to mitigate cognitive bias and promote a culture of safety through staff training and accountability. The report concludes by highlighting the need for comprehensive measures to prevent similar errors and enhance patient safety within the healthcare setting.

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

Root Cause Analysis 4
limited to surgical, anesthesia, nursing staff, theatre staff as well as patient support group
members (Tichanow, 2016). It is mandatory for the protocol to have specific and concise
guidelines that do not allow ambiguities that may lead to varied interpretations. The use of
anatomical marking form can be used as a replacement of the universal protocol and can thus be
important in avoiding surgery on the wrong area.
The physicians should ensure that they mention the side in the case of bilateral organs in
every letter or document that is written in the clinic. Responsibility should also be given to the
consultant in charge or the operating surgeon to ensure that it is only a single person charged
with marking the site of the surgery before the patient is taken to the operating room or to the
ward. Crucially, before commencement of the operation the surgeon must approve that the site of
surgery is correct by checking the clinic letter, consent form, theatre list, imaging studies and
also, and perhaps most significantly, with the person undergoing the operaation.
There should be pauses during the operation to make sure that the correct procedure is
being followed. The surgeon should also ensure that the right site as well as correct laterality are
being operated on and used respectively (Lin, Wernick, Tolentino and Stawicki, 2018). A
standardized time out process should be performed with all staff members given at least one
responsibility. Staff members should also be encouraged to voice their opinions freely.
It is also important to ensure that all the documents agree with the details of the surgery
before the operation. A staff member should, therefore, check the informed consent form of the
patient as well as the procedure of the surgery and the pre-operation note of the doctor involved
in the operation. In case of any inconsistencies, the physician and patient should consult on the
best course of action (Lin, Wernick, Tolentino and Stawicki, 2018). This would ensure that there
is no misinformation or misinterpretation of the operation procedure.

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Each staff member involved in surgery should also be assigned a role (Okes, 2019). It is
also important to ensure that every team member is involved during the time out process and is
also empowered to speak up freely in case they notice something out of the ordinary.
Existing Organizational Resources
It is also important to avoid concentrating all efforts in avoiding errors in operation only
in the operating room. Other areas of the hospital should also be involved in avoiding these
errors (Latino et al., 2019). The departments. The organization should, therefore, implement
system-based strategies to mitigate the risk of cognitive bias from affecting the safety of the
patient.
The code of conduct of the personnel involved in the operation should be discussed
especially during daily safety huddles (Tichanow, 2016). The staff should also be educated to
avoid intimidating and disrespectful behaviors that might affect the safety of the patient.
Accountability should also be encouraged among the staff to ensure that they conduct themselves
professionally.
The leadership should also hire additional personnel to improve coverage for concurrent
procedures (Black, 2019). Also, to counter the potential lapse in concentration of the staff
members involved in any operation, the hospital should create a structure and process to provide
feedback to ensure that the care members reported and made suggestions geared towards
improving the health care given to patients.

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References
Black, J. M. (2019). Root Cause Analysis for Hospital-Acquired Pressure Injury. Journal of Wound
Ostomy & Continence Nursing, 46(4), 298-304.
Kung, J. W., Brook, O. R., Eisenberg, R. L., & Slanetz, P. J. (2016). How-I-do-it: Teaching root cause
analysis. Academic radiology, 23(7), 881-884.
Latino, M. A., Latino, R. J., & Latino, K. C. (2019). Root cause analysis: improving performance for
bottom-line results. CRC press.
Lin, A., Wernick, B., Tolentino, J. C., & Stawicki, S. P. (2018). Wrong-site procedures: Preventable
never events that continue to happen. Vignettes in Patient Safety, 2, 2113.
Okes, D. (2019). Root cause analysis: The core of problem solving and corrective action. Quality Press.
Tichanow, S. (2016). Wrong site surgery: A critical incident analysis of a near miss. Journal of
perioperative practice, 26(1-2), 11-15.