ROOT CAUSE ANALYSIS OF A SAFETY PROBLEM

Root Cause Analysis Paper

Nickie Enos
BSMCON
Quality and Safety in Nursing 1
NUR 3206 Dr. Dowling
July 3, 2016
I pledge

ROOT CAUSE ANALYSIS OF A SAFETY PROBLEM

Root Cause Analysis of a Safety Problem

A root case analysis is the process of collecting data, investigating, determining causes,
implementing corrective actions, and monitoring the interventions for sustainability (Marquis
and Huston, 2009). Through root cause analysis, an organization is able to determine all causes
and ways to help change processes that are ineffective or unsafe. The use of a fishbone diagram
is a visual tool to identify possible causes of a problem or unwanted patient outcome.
I currently work in the Outpatient Infusion Center (OPIC) at the Bremo location. The
problem the staff encounters on a daily basis is the long wait times to treat chemotherapy
patients. The wait times are when the patients go upstairs to see the oncology doctor, waiting for
labs to result, and ordering the chemotherapy medications from the time the meds are ordered
until the medications are ready for pick-up from pharmacy. The patient spends more time
waiting to get treatment then actual infusion time. How can the infusion center help reduce the
wait times? Through root cause analysis, I am hoping to find areas that will improve the wait
times.
This is a problem for healthcare organizations because patient satisfaction is a driving
force behind financial reimbursements from Centers for Medicare/Medicaid Services (CMS) and
private insurance companies. HCAHPS is a survey instrument that collects data on patients
perceptions of their hospital encounters (CMS.gov, 2014). This public reporting of the survey
results has lead CMS to give incentives for health organizations to improve quality of care
(CMS.gov, 2014). This method of reimbursement is also known as pay-for-performance.
Providers are rewarded for quality, not quantity, of care delivered to patients (Amer, 2013). If a
hospital fails patient satisfaction surveys, annual payments from CMS results in a reduction of 2

ROOT CAUSE ANALYSIS OF A SAFETY PROBLEM

percentage points (CMS.gov, 2014). This can result in severe losses in reimbursements from
CMS for a hospital or provider.
I have identified some causes to the problem of wait times: no dedicated lab for
outpatient infusion center (OPIC), no dedicated pharmacy for OPIC, incorrect orders, lack of
equipment, not enough beds/chairs based on patient census, not enough nurses for patient census.
The problem with having no dedicated laboratory to process lab work is the time spent
waiting for labs to results and having a staff member or volunteer available to run the labs once
drawn. The OPIC has to take labs to the main hospital laboratory. The main hospital laboratory
has to process all the labs drawn from units within the hospital. The lab work takes up to two
hours for labs to result even though the labs ordered stat. Chemotherapy drugs can cause
penias, deficiencies in blood cell counts. This is important to monitor so a patient does not
become so neutropenic that he/she requires hospitalization.
The problem with no dedicated pharmacy to make the chemotherapy medications
increases wait time for patients. Just like the laboratory, the pharmacy also services the entire
hospital. Chemotherapy drugs are dependent on patients weight. Therefore, the patient has to
have current weight and the results of lab work before the pharmacy will make the chemotherapy
intravenous (IV) infusions. Once you have all the correct information, the pharmacy has to
mix/make the IV infusions, which takes time. When the medications are ready, the OPIC has to
send a runner to retrieve the medications from the pharmacy, again, adding to the wait times.
Clinical ambulatory patient experience is greatly influenced by long wait times negatively
affecting patient satisfaction scores (Bleustein and et.al, 2014). Increased wait times negatively
affect perceptions of physicians and caregivers as giving less quality of care (Bleustein and et.al,
2014).

ROOT CAUSE ANALYSIS OF A SAFETY PROBLEM

The next problem is a safety issue also. Incorrect orders pose a serious safety issue.
Orders have to have diagnosis code, date, time, MD/NP/PA signature, dose based on kilograms
(kg) or body surface area (BSA), medication, route, number of cycles, number of days to be
given per cycle, just to name a few. This would fall under the policy and procedures cause of
increased wait times. When orders are not properly completed, the nurse has to contact MD
office to update orders. Prescription errors are the most common medical error in hospital and
ambulatory settings (Jayawardena and et. al., 2007). Most of the time there is unqualified staff
members in MD offices to take verbal orders or to give verbal orders so that leads to waiting
until the MD is available to update the order. A fax machine is an essential piece of equipment to
help decrease wait times. A standardized computer-physician-order-entry system (CPOE) has
helped reduce medication dosage errors (Jayawardena and et. al., 2007). With a standardized
system of order entry, physicians are forced to enter orders without forgetting to enter important
and required information reducing incomplete orders and wait times for patients.
The last cause of long wait times I will discuss is the inadequate staffing of Registered
nurses (RN) based on patient census. On some days, a nurse may have up to seven patients to
attend to their care. This creates an over-stressed and hurried atmosphere leading to increased
wait times and safety concerns for patients in their care. Research clearly shows that care is
safer when nurse-to-patient ratios are reasonable (Amer, 2013, p. 25). Patients in the afternoon
can wait up to an hour before a nurse can get them in a chair to start the process of treatment for
the day. Nurses cannot possibly care for complex patients and meet all their needs when there
are inadequate resources, including time (Amer, 2013, p. 23). When the patient census is high
for the day, the OPIC runs out of beds/chairs impeding the nurses ability to care for patients,
which increases the times patients wait to have treatment.

ROOT CAUSE ANALYSIS OF A SAFETY PROBLEM

Through a root cause analysis, I was able to find causes that impact patient wait times.
What I found is that one cause leads to a delay in another cause, which exacerbates patient wait
times, profoundly effecting patient satisfaction. Care, that is patient-centered, is important in the
delivery of safe, quality health care (Amer, 2013). The three factors that shape patient-centered
care: coordination and integration of clinical care, coordination and integration of ancillary and
support services, and coordination and integration of frontline patient care (Amer, 2013, p.
199). To increase patient satisfaction of wait times, the coordination of ancillary departments
and OPIC needs to be improved. This is an organizational problem and not just one person or
one department. It may be essential to start a dialogue with senior management and executive
members of the organization to bring this safety problem to their attention.

References
Amer, K. S. (2013). Quality and safety for transformational nursing: core competencies. Upper

ROOT CAUSE ANALYSIS OF A SAFETY PROBLEM

Saddle River, N.J.: Pearson Education, Inc.

Bleustein, C. and et. al. (2014). Wait times, patient satisfaction scores, and the perception of
care. American Journal of Management Care, May 2014, 20(5), p. 393-400. Retrieved
online June 14, 2016 from http://www.ncbi.nlm.nih.gov/pubmed/25181568
CMS.gov. (2014). HCAHPS: patients perspectives of care survey. Centers for Medicare and
Medicaid Services, modified September 25, 2014. Retrieved online June 14, 2016 from
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessmentinstruments/HospitalQualityInits/HospitalHCAHPS.html
Jayawardena, S. and et. al. (2007). Prescription errors and the impact of computerized
prescription order entry system in a community-based hospital. American Journal of
Therapeutics. July/August 2007, 14(4), p. 336-340. Retrieved online June 14, 2016 from
http://journals.lww.com/americantherapeutics/Abstract/2007/07000/Prescription_Errors_
and_the_Impact_of_Computerized.5.aspx. DOI: 10.1097/01.mjt.0000209681.22077.b9
Marquis, B. L. and Huston, C. J. (2009). Leadership roles and management functions in
nursing: theory and applications. (6th ed.). Philadelphia, PA.: Wolters Kluwer/
Lippincott Williams & Wilkins