Description: The purpose of the nurse-led initiative is to bring root cause analysis (RCA) to the unit level. The goal was to increase nurses’ involvement in advancing efforts and to identify opportunities for improvement when adverse events occur, especially hospital-acquired events (CAUTI, CLABSI, HAPI, falls). Front-line staff requested a better way to disseminate the information that was being presented in the traditional RCA to those that are participating in direct patient care in order to ensure that they were involved in the action planning.
This new RCA process provides the staff nurse and the manager the ability to evaluate each patient event in an efficient, systematic manner and leads to bedside nurse participation in the development of the action plan.
Methodology: Traditionally, RCA results are gathered and compiled by the manager and then presented to a select group of front-line staff and other leaders that are part of the specific workgroup. The new process provides the staff nurse and the manager the ability to evaluate patient events in an organized, efficient, methodical manner and allows front-line staff to participate in developing the action plan. The results of the RCA are then presented on the unit where the event occurred, allowing all staff to be included in the discussion of the problem, the results, and the interventions suggested by their peers. All staff are encouraged to provide input on identifying causes and solutions presented.
Results: The new process was implemented with the HAPI committee and the falls workgroup. RCAs are no longer felt to be a punitive event. The report out is an opportunity to learn, creating a no-blame culture centered on zero harm. A non-formal event that facilitates honest conversation in a blameless environment. It has transitioned from a one-way conversation to open sharing and ownership of patient events. Events are identified and acted upon quicker.
Due to the implementation of the new process, one fall safety event report on the neuro critical care unit led the staff to realize that they did not have chair alarms, and as a result, the unit was outfitted with chair alarms and have had no falls since this intervention. On the neuro unit during the pressure injury RCA, it was noted by the nursing assistants that they wanted ownership of alerting nursing staff about skin issues and potential HAPIs. A process and a tool were developed to facilitate communication between the staff to prevent additional events associated with HAPIs. As a result, the lines of communication between the CNA staff and the nursing staff are more open, and more importantly the patient is the beneficiary. The new process has since been expanded to the CAUTI and CLABSI workgroups. We will continue to monitor the patient outcome data in order to track results of the change