DDHA 8103 Week 2 Event Chronology Analysis Example

Twenty Minutes on a Hot Pack: A Factual Chronology of a Partial-Thickness Burn at a Composite Outpatient Rehabilitation Clinic, With Observation Kept Apart From Inference

Student Name

Walden University

DDHA 8103: Advanced Healthcare Quality and Risk Management

Instructor Name

Month Day, Year

Twenty Minutes on a Hot Pack: A Factual Chronology of a Partial-Thickness Burn at a Composite Outpatient Rehabilitation Clinic, With Observation Kept Apart From Inference

Purpose and Scope

This analysis sets down what happened during one afternoon appointment last spring at Millbrook, one of the twelve physical therapy clinics run by Hollins Ford Health, an invented regional system, and what happened in the three days after it. The patient, here called Mr. T., is 74, has had type 2 diabetes for many years and was attending his fourth visit for chronic low back pain. He left the clinic with redness on his lower back that became a partial-thickness burn. The document has one job: to produce an account of the event that every person involved can accept as accurate before anyone argues about why it happened. It therefore stops at the edge of explanation. Causes, contributing conditions and corrective actions belong to the root cause analysis that follows, and words such as failed, should have and inadequate do not appear in the chronology.

Sources Used

Five sources were used. Listing them lets a reader judge how much weight each fact can bear. The first is the electronic visit record, including the flowsheet entries for the moist heat application and their time stamps. The second is the heating unit's temperature log for that week. The third is interviews held within six days of the event with the treating physical therapist, the rehabilitation aide who applied the pack, the front desk coordinator and the clinic manager. The fourth is a telephone conversation with Mr. T. and his daughter, held with their agreement after the disclosure conversation. The fifth is the burn clinic's visit note, shared by Mr. T. Where these sources disagree, the disagreement is recorded rather than resolved. Interviews were held separately, and no participant saw another's account before giving their own.

Chronology

The chronology shows an ordinary visit. The exercise portion ran its usual length, the heat was applied after exercise as the plan of care described, and the five-minute check was carried out and recorded. Two moments carry most of the weight in what follows: the change of position at 4:07 p.m., and the first look at the skin at 4:28 p.m. Both are described from the accounts of people who were present, and neither account is disputed by the others.

Table 1

Sequence of Events, Visit Day and Following Three Days

Times come from the record where it holds them and from interviews where it does not; the two interview-based times at 4:07 and 4:28 p.m. are estimates.

What Was Observed and What Was Inferred

Event documents are most often contaminated when an inference is written in the grammar of an observation. The pairs below keep them apart. Each inference is labeled as such and none is used in the chronology above.

Several of these inferences are plausible, and the clinical literature on heat and pressure gives reasons to expect some of them. That is exactly why they are held back. A chronology that already contains the expected explanation tends to steer the root cause analysis toward confirming it, and Vincent et al. (1998) caution that analyses starting from the most visible act often stop there, missing the conditions around it.

Table 2

Observations and the Inferences Drawn From Them

The right-hand column may prove correct, but each item is a conclusion that the root cause analysis must test rather than assume.

Disagreements Between Sources

Three points are not settled. First, the aide recalls placing one extra towel beneath the cover, while the therapist recalls being told there were two. Second, Mr. T. remembers saying at the check that the heat was getting hot, while the aide recalls the word fine; both may be accurate, since a patient can say both things in a few seconds. Third, the clinic manager believes the practice of letting patients lie on packs was uncommon at Millbrook, while two staff members describe it as frequent for patients who cannot lie face down. These disagreements are recorded as they stand. Resolving them now would mean choosing whose memory to trust, which is a judgment the analysis team should make with all of its evidence, not one an event writer should make alone.

What Is Not Yet Known

Several facts that matter are not yet available. The temperature of the specific pack used is unknown, because pack temperature is not recorded at the time of use. Whether Mr. T. has reduced sensation in the lower back has not been formally tested. How many patients across the division have received moist heat while lying on the pack is unknown, because positioning is not documented. Whether the burn will leave a scar will not be known for several months. Published guidance recommends that an event review list what is unknown, so that the analysis team can decide which gaps to close and which to accept (National Patient Safety Foundation, 2015).

Holding the Explanation Back

The temptation in a document like this is to end with a sentence that sounds like a finding, such as that the patient should not have been positioned on the pack. That sentence may become a finding, but it is not one yet, and writing it here would do two kinds of harm. It would place the aide at the center of the story before the conditions around the aide's choice are examined, and it would give the root cause team a conclusion to defend instead of a question to answer. Peerally et al. (2017) describe how investigations in health care often settle on the individual nearest the event and then propose weak fixes such as reminders and retraining. A clean chronology is the first defense against that pattern.

Conclusion

Mr. T. spent 20 minutes lying on a moist hot pack placed under his lower back, positioned that way at his request and with an added towel, and a documented five-minute check found him comfortable. Pink skin was seen at removal, blisters appeared the next morning, and the burn clinic recorded a partial-thickness burn on the third day. Three points remain disputed and four facts remain unknown. The next document will argue causes. This one is finished when everyone involved agrees that it describes what happened.

References

National Patient Safety Foundation. (2015). RCA2: Improving root cause analyses and actions to prevent harm. Institute for Healthcare Improvement. https://www.ihi.org/library/tools/rca2-improving-root-cause-analyses-and-actions-prevent-harm

Peerally, M. F., Carr, S., Waring, J., & Dixon-Woods, M. (2017). The problem with root cause analysis. BMJ Quality and Safety, 26(5), 417-422. https://doi.org/10.1136/bmjqs-2016-005511

Vincent, C., Taylor-Adams, S., & Stanhope, N. (1998). Framework for analysing risk and safety in clinical medicine. BMJ, 316(7138), 1154-1157. https://doi.org/10.1136/bmj.316.7138.1154