Weeks 6. Root Case Analysis

ROOT CAUSA ANALYSIS
BY
HARYATININGSIH PURWANDARI
09/23/2023 1
LEARNING OBJECTIVE
The students will be able to :

• Implementing the root cause analysis (RCA) in the case study
• Explain Failure Mode Effect Analysis (FMEA)
09/23/2023 2
Case title: The Lewis Blackman Story
• Lewis Blackman, aged 15, was admitted to a South Carolina hospital. Lewis
was admitted to the adult ward for routine surgery to correct a congenital
chest deformity. After surgery, he received a strong painkiller, ketorolac. Lewis
complained of stomach pains and complained that the pain in his stomach
was getting worse. The nurse who received Lewis' complaint said that
postoperative pain was normal. Lewis' condition worsened and then he died.
• To clarify the case, the group needs to take the time to study the chronology
of events presented by the patient's parent, Ms Helen Haskell. Please, watch
the following videos to learn more about the Lewis Blackman case: QSEN: The
Lewis Blackman Story, Part 1. (6:46 min.) Talk by his mother, Helen Haskell.
https://www.youtube.com/watch?v=WElE_hRucpo
09/23/2023 3
GROUP DISCUSSION TASK
• 1. Summary of the investigated incident.
• 2. Make as many case notes as possible.
• 3. Based on the records, determine what factors caused the incident? Focus
on nursing aspects. Explain whether there is a “just culture” factor that
influences this incident?
• 4. What are your suggestions for institutions to ensure that this incident does
not recur? How to develop a culture (safety culture)?
• 5. What are the implications of this case for you? What lessons did you learn
from this case?
09/23/2023 4
ROOT CAUSE ANALYSES/ RCA
(IDENTIFIKASI AKAR MASALAH)
• Root Cause Analysis is a structured evaluation method for

identifying the root causes of unexpected events and adequate
measures to prevent the same event from happening again
• Root Cause Analysis adalah metode evaluasi terstruktur untuk
identifikasi akar masalah dari kejadian yang tidak diharapkan dan
tindakan adekuat untuk mencegah kejadian yang sama terulang
kembali.
09/23/2023 5
REVIEW (FROM THE PREVIOUS LECTURE)
• Patient Safety is a system by which hospitals make patient care safer.

• The system includes risk assessment, identification and management of
matters related to patient risk, incident reporting and analysis, the ability to
learn from incidents and their follow-up and implementation of solutions to
minimize risks.
• The system is expected to prevent injuries caused by errors resulting from
carrying out an action or not taking the action that should be taken.
09/23/2023 6
• Keselamatan Pasien adalah suatu sistem dimana rumah sakit membuat
asuhan pasien lebih aman.
• Sistem tersebut meliputi pengkajian risiko, identifikasi dan pengelolaan hal
yang berhubungan dengan risiko pasien, pelaporan dan analisis insiden,
kemampuan belajar dari insiden dan tindak lanjutnya serta implementasi
solusi untuk meminimalkan timbulnya risiko.
• Sistem tersebut diharapkan dapat mencegah terjadinya cedera yang
disebabkan oleh kesalahan akibat melaksanakan suatu tindakan atau tidak
melakukan tindakan yang seharusnya dilakukan.
09/23/2023 7
• Patient Safety (WHO) Patient safety is the absence of harm to a patient during the
process of health care
• Keselamatan pasien adalah tidak adanya bahaya untuk pasien selama proses
perawatan).
• Patient Safety Incident is any event or situation that can result in or is likely to
result in harm (illness, injury, disability, death, etc.) that should not have occurred
• Insiden Keselamatan Pasien adalah setiap kejadian atau situasi yang dapat
mengakibatkan atau berpotensi mengakibatkan harm (penyakit, cedera, cacat,
kematian dan lain-lain) yang tidak seharusnya terjadi).
09/23/2023 8
WHAT IS ROOT CAUSE ANALYSIS (RCA) ?
APAKAH RCA?
• It is a structured approach to incident analysis (pendekatan untuk analisis
insiden keselamatan pasien).
• It was first established by the National Center for Patient Safety of the US
Department of Veterans Affairs (yang membuat RCA).
• The RCA model focuses on prevention, not blame or punishment (fokusnya
pencegahan, bukan menyalahkan atau menghukum).
• The focus of this type of analysis is on system-level vulnerabilities as opposed
to individual performance (focus pada analisis tingkat system yang rentan).
09/23/2023 9
• The model examines multiple factors, such as communication, training, fatigue,
scheduling of tasks/activities and personnel, environment, equipment, rules, policies
and barriers (model ini mengkaji banyak factor seperti komunikasi, latihan, keletihan,
jadwal tugas, lingkungan, peralatan, nilai, kebijakan dan hambatan).
• RCA focuses on the system, not the individual worker, and assumes that the adverse
event that harmed a patient was caused by a system failure (focus pada system, tidak
pada individu, dan mengasumsikan kejadian tidak diharapkan yang membahayakan
pasien berasal dari kesalahan system).
09/23/2023 10
A severity assessment code is used to help triage reported incidents to ensure
that those indicating the most serious risks are dealt with first (Kode penilaian
keparahan digunakan untuk membantu melakukan triase insiden yang
dilaporkan untuk memastikan bahwa insiden yang menunjukkan risiko paling
serius ditangani terlebih dahulu).
09/23/2023 11
The defining characteristics of root cause analysis include (karakteristik
RCA):
• review by an inter-professional team knowledgeable about the
processes involved in the event (review oleh tim inter-professional
yang berpengetahuan tentang proses yang melibatkan kejadian).
• analysis of systems and processes rather than individual performance
(analisisnya lebih bersifat kepada system dan proses daripada
penampilan individu).
09/23/2023 12
• Deep analysis using “what” and “why” probes until all aspects of
the process are reviewed and contributing factors are considered
• Analisis mendalam menggunakan penyelidikan "apa" dan
"mengapa" sampai semua aspek proses ditinjau dan faktor-faktor
yang berkontribusi dipertimbangkan.
• Identification of potential changes that could be made in systems
or processes to improve performance and reduce the likelihood
of similar adverse events or close calls in the future.
• Identifikasi perubahan potensial yang dapat dilakukan dalam
sistem atau proses, untuk meningkatkan kinerja dan mengurangi
kemungkinan kejadian buruk serupa atau panggilan dekat di masa
depan. 09/23/2023 13
ROOT CAUSE ANALYSIS QUESTIONS
PERTANYAAN RCA
1. What happened? Apa yang terjadi?
2. Who was involved? Siapa yang terlibat?
3. When did it happen? Kapan itu terjadi?
4. Where did it happen? Dimana itu terjadi?
5. How severe was the actual or potential harm? Seberapa bahaya yang actual
atau potensial?
6. What is the likelihood of recurrence? Apa kemungkinannya terulang?
7. What were the consequences? Apa konsekuensinya?
09/23/2023 14
Thank you
09/23/2023 15

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ROOT CAUSA ANALYSIS

The students will be able to :

• Root Cause Analysis is a structured evaluation method for

• Patient Safety is a system by which hospitals make patient care safer.

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