Root Cause Analysis - NPUAP€¦ · •Fishbone diagram helps to examine ... Root cause analysis...

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©2015 National Pressure Ulcer Advisory Panel | www.npuap.org

Root Cause Analysis

Joyce Black, PhD, RN, CWCN, FAAN

Background

• Process to determine why a problem

happened in the first place, so it wont

happen again

• Correcting the symptom alone is a waste

of resources

• Be aware of bias

– Intentional and unintentional

• Finding the root of the problem is not

easy work

– But if the latent source of the problem can be

found you can get rid of the problem©2015 National Pressure Ulcer Advisory Panel | www.npuap.org2

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©2015 National Pressure Ulcer Advisory Panel | www.npuap.org3

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• Is this wound a pressure ulcer?

– Was it due to pressure?

– Was it due to shear?

• Is this wound on a previously healed PrU?

• When was this wound discovered?

– What size, stage, location?

– Due to a medical device? On mucous

membrane?

• What was risk score

– Was it accurate?

– Did a prevention plan stem from the score?

Starting with the pressure ulcer

• Stage at time of initial discovery

– Stage I --- likely began in last 12-24 hours

– DTI --- purple tissue without epidermal loss

likely began 48 hours ago

• Important because

– you might not have had this patient 48 hours ago

– Turning may have been impossible

» OR cases

– Stage II --- likely began in last 24 hours

– Stage III-IV --- began at least 72 hours ago

Determining the timing of the ulcer development

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• Pressure ulcers

skin on top of

buttocks cleft

• Patient was

supine at time of

pressure

– This is a DTI that

occurred in the

OR

Examine the location of the ulcer at discovery

• This patient’s

head was

elevated when

pressure

applied

– DTI nearer to

sacrum

Ulcer location

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• This patient was

lying on his side

when DTI

developed

– Ulcer on the side

of heel

Location of pressure ulcer

• If due to pressure, what preventive practices

were carried out?

– Turning? How often? What angle was the patient

off the surface?

• If the patient could not be turned was the surface

upgraded?

– Were heels elevated? Was elevation continuous?

– Was the surface upgraded due to high risk?

• Was the patient turned regardless of the surface?

• Is the surface working?

– Was the patient repositioned hourly in a chair?

• Was a chair cushion used?

• Was the cushion working?

RCAs continued

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• If due to microclimate…

• Was the skin kept clean and dry?

– Was incontinent urine and stool quickly

removed?

• Was the method of skin cleansing nonabrasive?

• Was the skin protected against next exposure?

– Was the skin moisturized?

– Was an incontinent brief removed for several

hours each day?

– Was a low air loss or microclimate surface

used?

RCAs continued

• If due to shear…

• Was the body areas subjected to shear

protected?

– Dressings on sacrum in HOB up patients?

– Padding in chair if patient slouches or is in

recliner chair

RCAs continued

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• If due to protein calorie malnutrition

– Was the patient hydrated and fed at the

dietician’s recommendations?

• Were supplements consumed?

• Was swallowing addressed?

• If not, was the deviation explained?

• E.g., Advanced Directives

RCAs continued

Looking at Human Roots

• Difficult aspect– beware of bias

• Consider competing priorities

– What is the unit of origin

• Predominately in ICU?

– How many actually started in OR? ER?

– Is the ICU bed designed for prevention?

• Examine training/competencies

– Are skin care/pressure ulcer competencies

done annually?


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Consider the patient

• If the patient is aware of the ulcer

– Does he know when it started?

– Does he know why it happened?

– Did he tell anyone?


This patient's DTI was

discovered when her stockings

were removed

What does she know about this

ulcer?

• Defined as volatile blood pressure and/or

oxygen saturation with movement

– It is not simply the use of vasopressive meds

– Concerns arise when document shows

patient moved for diagnostics or care, but

cannot be turned

• Can turning be done slowly?

• Can heels be elevated?

– Was surface upscaled to reduce pressure,

shear and microclimate?

– When on lateral rotation surface

• Was patient turned at all?

• Did bed do all the turning?

A closer look at hemodynamic instability

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Human Factors

• Educators spend little

time on bedside care

– Do not expect new

grads to be able to

“see” when a patient

can be turned or “how”

to actually turn the

patient

• If hospital pillows are

thin, when combined

with inadequate

turning…

• Leads to stripe

appearance to

pressure ulcers

along buttocks

cleft

• Pressure ulcer prevention must become

a lifestyle for some patients

– Find ways to help them adapt

• If nonadherence is present

– Document it factually

– Document what you told them and what they

did

– Be certain your awareness of nonadherence

and the documentation appears in the record

before the ulcer starts

Considering Nonadherence

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• Classify as quality improvement to

reduce discovery

• Use the location and stage at discovery

to find the timing of the ulcer

– What was happening to patient at that time?

• Was pressure ulcer prevention possible?

• If yes, was it carried out? Documented?

Using RCA data

What are the latent roots in your pressure ulcer prevention system?

• Over reliance on beds

– Creating narrow ulcers along gluteal cleft

• PrU prevention not a priority

– “We are saving lives, we can’t worry about

skin”

– Under appreciation for seriousness of ulcers

• Lack of expectation for complete skin

assessment

– Ulcers beneath medical devices

– Ulcers found at more advanced stages


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Other Root Causes

• Lack of awareness and accountability for

– Policies and guidelines

• Prevention bundle

• Braden scale scoring

– Proper staging of ulcers

– Availability of supplies/devices

– Documentation issues

• Insufficient

• EMR issues

– Communication issues

• Nurse to nurse

• Nurse to others From Prince, 2010©2015 National Pressure Ulcer Advisory Panel | www.npuap.org21

Bringing it all together

• Fishbone diagram helps to examine

– Performance and Feedback

• Are your unit pressure ulcer rates posted?

– Skills and knowledge

• Are you including skin in yearly competencies?

– Motivation

• Are staff recognized for “a job well done”?

– Job expectations

• Are policies and procedures current? Accessible?

– Environment and tools

• How old are your beds on the units?

– Organizational support

• IS CNO on board?©2015 National Pressure Ulcer Advisory Panel | www.npuap.org22

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Ishikawa (1985; 1990)


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©2015 National Pressure Ulcer Advisory Panel | www.npuap.org

Root cause analysis has to be done with rigor in order to find the true roots


Root Cause Analysis - NPUAP€¦ · •Fishbone diagram helps to examine ... Root cause analysis...

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