Wednesday, September 7, 2011

A Coloring Page for Root Cause Analysis

The other day #2 boy brought home a coloring sheet from church.  I asked him to tell me about his picture.  He went into a wonderful description of the story of David and Goliath.   Goliath was colored blue similar to a giant smurf and David was wearing a green skirt.  He had added grass, bushes, and even some small animals.  His hands flew through the air describing his well colored picture and telling me in detail that Golliath blue from him blueberry pancakes and why David was “late to the party”.  As he talked, I began to focus in on the upper corner of his paper to the small gray airplane.  “What is that?” I asked.  Tucker’s eyes lit up and he replied “That’s the fighter pilot backing up David in case he missed.”

It's interesting when we begin see the outline of a picture and think we have the whole story.    

As I have been reviewing RCA’s from different hospitals and researching the rebuild of the incident – I find it interesting that many hospitals do not build the picture from data that is very representative of what is occurring in the room.   Many times this is simply that they do not know that the data is available or that they have systems in place that the data is locked inside and not accessible. 

I was working with a hospital on a fall analysis - extracting data to begin to layout the outline of a picture of what happened surrounding the patient fall.   The patient requests and responses are a lot like a blank coloring sheet.  The outline is your basic patient request data and based on the patterns it began to paint a picture.  The physiological alarm data, the medication data, and other bits and pieces began to color in the outlines to give a full view of what was occurring in that patient’s room.   Did the patient have a critical telemetry alarm?  Who received it? What were they doing?

Another interesting piece of the puzzle is communications between caregivers.  I was having a conversation with Voalte’s Trey Laudedale about the value of the Text Message.   As I was thinking about this blog it occurred to me – the text messages are the hand drawn fighter jet in the picture.  Sometimes the outlines and the information we are looking for does not create the whole picture. Sometimes the picture needs to have more data then what we would normally consider to complete it.  

So here is my tip for an RCA
·         Review the Patient Requests from the Nurse Call and Response of the Caregivers
·         Review the Physiological alarm data that was sent to the Caregivers
·         Review the text messages between clinicians

Remember data is always available if you are careful to set up your technology correctly.

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Kourtney Govro