DDHA 8103 Week 3 Root Cause Analysis Example

Past the Aide Who Placed the Pack: A Root Cause Analysis of a Moist Heat Burn Across a Twelve-Clinic Rehabilitation Division, With an Owned Action for Every Cause

Student Name

Walden University

DDHA 8103: Advanced Healthcare Quality and Risk Management

Instructor Name

Month Day, Year

Past the Aide Who Placed the Pack: A Root Cause Analysis of a Moist Heat Burn Across a Twelve-Clinic Rehabilitation Division, With an Owned Action for Every Cause

Event Summary

Hollins Ford Health runs twelve outpatient therapy clinics, and this composite case comes from the one at Millbrook. Mr. T., who is in his seventies and lives with diabetes, was given heat for low back pain at the end of an exercise session. Because face-down positioning hurt his shoulder, he lay face up with the wrapped pack under his lumbar spine for the full treatment time. The aide's check at minute five recorded no complaint. Pink skin at removal had blistered by the following day, and a burn specialist measured a partial-thickness wound roughly 10 by 14 centimeters two days later. The agreed chronology, with its disputed points and open questions, was completed the week before this analysis began.

Method

The analysis followed the approach set out by the National Patient Safety Foundation (2015). A team of six met four times over three weeks: the division's quality director as facilitator, a physical therapist and an aide from clinics other than Millbrook, a clinic manager, a patient safety officer from the hospital and a patient advisor. No one directly involved in the event sat on the team, though all were interviewed. The team observed moist heat set-ups at four clinics, examined the heating units and covers in use, read the division's modality procedure and its training materials and tested pack surface temperatures with a calibrated probe. To keep the inquiry from stopping at the person nearest the event, it sorted findings with the contributory factor framework of Vincent et al. (1998), which looks at the task, the patient, the individual, the team, the work environment and the organization in turn. The team avoided a single chain of why questions, because Card (2017) shows that a single line of whys usually commits early to one branch and leaves contributing causes running beside it unexamined.

The Proximate Act

The act closest to the harm was the placement of Mr. T. on top of the pack, with one or two added towels in place of positioning him face down or on his side. The aide made that choice at the patient's request, after he said lying face down hurt his shoulder, and the therapist was told. Had the analysis stopped here, the obvious action would have been to retrain the aide. The team set that action aside until it had examined why a sensible employee made a choice that the procedure discouraged and that colleagues at other clinics described making as well.

Contributing Conditions

Five conditions made the act likely and its harm possible. First, the written procedure said patients should avoid lying on hot packs but gave no alternative for those who cannot lie prone, and it was silent on what an aide should do when the two collide. Second, the practice of adding towels and letting the patient lie on the pack had spread quietly. At observation visits, staff at seven of the twelve clinics described using it, and none had heard it was a problem. Third, the aide was covering two treatment tables and a third patient's set-up, so the five-minute check was a quick question from the curtain rather than a look at the skin. Fourth, the check depended on the patient's report, and the intake form's numbness question did not ask about the area being treated. Fifth, probe testing showed that the pack's surface temperature under a seated adult's weight, through the same towel stack, rose well above the temperature measured with the pack lying free, which matches the explanation that compression removes the towels' insulating air.

Latent Factors

Behind those conditions sat three features of the division itself. The audit program checked whether the five-minute skin check was documented, which it always was, and had no means of seeing positioning. The modality procedure had been written for an earlier generation of heating units and covers and had not been revised in eight years. And staffing ratios had been set on the assumption that passive modalities need little attention, which shifted aides toward running several patients at once during heat applications. None of these features caused the burn by itself. Together they made a burn under these conditions a matter of time.

Cause Statements and Actions

Each cause statement below links a condition to the outcome, and each carries an action with an owner and a measure. Actions are graded by strength using the hierarchy set out by Hettinger et al. (2013), which places physical and forcing changes above standardization and both above training and policy reminders.

The strongest action available, removing moist heat from the service line, was considered and rejected for now. Moist heat is a common and valued part of care, and the team judged that a fitted cover and a firm positioning rule would remove the specific mechanism of this injury without taking a comfort measure away from thousands of patients. The board case later in the course revisits that judgment.

Table 1

Causes, Actions, Strength and Ownership

Retraining of the aide is not listed, because the conditions that led to the act apply to every aide in the division.

Testing the Analysis Against Its Limits

Peerally et al. (2017) warn that root cause analyses in health care produce many recommendations and few strong changes, and that teams often lack the authority to change what they find. Three safeguards were built in. The facilitator reports to the vice president of ambulatory operations, who agreed in advance to respond to every action in writing within 30 days. Each action has a measure: the rate of injury defined in next week's measure specification, the share of observed set-ups with the patient on top of a pack and the share of first heat applications with an area sensation test recorded. And the team will meet again at 90 days to check whether the actions were carried out and whether they are working.

Conclusion

The burn followed from an act, but the act followed from a procedure with no alternative for a common patient need, a cover that allowed a substitute for that alternative, a check reduced by workload to a question, a screen that asked the wrong question and an audit that could not see the work. Five actions answer those five causes, and each has an owner, a measure and a date. The aide who placed the pack has been told in writing that the analysis found no individual fault.

References

Card, A. J. (2017). The problem with "5 whys." BMJ Quality and Safety, 26(8), 671-677. https://doi.org/10.1136/bmjqs-2016-005849

Hettinger, A. Z., Fairbanks, R. J., Hegde, S., Rackoff, A. S., Wreathall, J., Lewis, V. L., Bisantz, A. M., & Wears, R. L. (2013). An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions. Journal of Healthcare Risk Management, 33(2), 11-20. https://doi.org/10.1002/jhrm.21122

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