lRead theCase Study on page 213-214
A. Build a Root Cause Analysis onthe basis of the findings in this case study. (5 points)
There is an example in Figure 11.6.Use “WHY” questions to find the proximal and distalfactors.
B. What are the root causes of thissituation? (5 points)
C. Build a Fishbone Diagram (5Points). There is an example in Figure 11.5.
D. Using the root-cause analysis andthe diagrams, discuss how the hospital can prevent similarsituations (5 Points)
Transcribed Image Text from this Question
Case Study …. Derek Johnson, MD, has been an anesthesiologist at Community Hospital of the West for 15 years, He is 45 years old. The physician is board certified to perform all kinds of anesthesia procedures, including every type of surgical procedure and obstetrical anesthetic procedure. His colleagues have noticed for some time that he has become more and more haggard looking, but they ascribe this to the hectic work schedule that anesthesiologists often must maintain One day, Dr. Johnson was admitted to the intensive care unit at Community Hospital of the West. The news quickly spread through the organization. He was suffering from a compromised immune system and was close to dying from septicemia that had developed from abscesses in his arm as a result of injec- tions. Some of the OR nurses discussed the situation on their dinner break and speculated that Dr. Johnson was a drug addict. The current policy of the hospital was that anesthesiologists were not required to account for the narcotics that they administered to patients postoperatively. Some of the OR nurses had noticed over the past six months to a year that Dr. Johnson’s patients had morphine for pain prescribed, and that Dr. Johnson would administer this himself, even for patients who were not complaining of pain. Some of Dr. Johnson’s patients who were experiencing high levels of pain experienced little pain relief after supposedly receiving morphine administered by Dr. Johnson One of the nurses reported that three months earlier she had cornered the chief of the anesthesia service and told him of Dr. Johnson’s narcotics irregularities. Not wanting to challenge or accuse a fellow physi- cian, the chief said indignantly that there must be some other explanation and terminated the conversation. The nurse did not discuss the problem with anyone else-not the director of surgical services, the chief of surgery, the director of nursing, or an administrator. The possibility of personal addiction among healthcare workers is a job-related issue. Individuals who have access to pain medication and who frequently medicate others to help relieve pain can become caught in an addictive cycle themselves, especially when system processes fail to hold professionals accountable for narcotic use or abuse in the provision of patient care. Most agencies offer employees access to confiden- tial counseling. Unfortunately, many times those who have problems with alcohol or drugs are unable to see their problem and justify their use in a variety of ways. It is unfortunate that the facility did not have a mechanism in place for confidentially reporting the suspected abuse. It may have been possible to offer the physician a professional intervention that could have saved him physically and mentally from such severe trauma. Figure 11.6. Sample root cause analysis Level II Root causes Level 1 Proximate cause Proximate causes Why? Why? Why? Why? 11.5. Sample cause-and-effect diagram CAUSES EFFECT Methods Manpower 1 OB nurses Transport to OR takes too long not OR trained Death of Mrs. Yu Slow elevator Surgical equipment not in DR Surgical supplies not in DR Material Machinery
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