Root Cause Analysis 1

Running head: ROOT CAUSE ANALYSIS USING FISHBONE DIAGRAM

Root Cause Analysis Using Fishbone Diagram

Janet Heath

Bon Secours Memorial Nursing School

Quality and Safety in Nursing

NUR3206

Instructor Catherine Mikelaites, MSN, RN-BC, CMSRN

Assistant Professor Mrs. Tomeka Dowling, RN, MS

October 23, 2014

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Root Cause Analysis Using Fishbone Diagram

What is the definition of root cause analysis? Wikipedia defines it as a method of

problem solving that tries to identify the root causes of faults or problems. A root cause is a

cause that once removed from the problem fault sequence, prevents the final undesirable event

from recurring (RCA, n.d.).

What better problem to attempt solving than one that has been a safety issue for a loved

one? During the spring, my mother had a fever, dyspnea, cough, wheezing, tachypnea and

hypoxia (Schmitt & Burg, 2012). I was working the weekend but when I spoke with her over the

telephone, it was obvious that she was having difficulty breathing. I could, actually, hear

wheezing over the phone line. I immediately knew something was wrong, left work, and took

her into the emergency department. Even though, I knew that she was extremely sick, I thought

it would be a simple pneumonia. At worst, she would stay a couple of nights to receive IV

antibiotics, nebulizer treatments, steroids, and oxygen. However, in spite of treatment, her

symptoms, progressively, got worse. While caring for my mother in the hospital, I noticed a

large bruise on her right lower leg and questioned her about what happened. She had fallen

several weeks prior to this illness, unbeknown to me. My gut immediately thought of pulmonary

embolus. I did not want to jump to conclusions but started asking questions. As it states in the

American Journal of Emergency Medicine, delay in diagnosis of an acute PE is frequent despite

current diagnostic strategies. Patients are sent home or admitted into the hospital with a wrong

diagnosis depending on clinical presentation or coexisting medical conditions (Torres-Macho et

which would have alerted the hospital to do more testing. After expressing concern, the

physician ordered a CT of the chest. My mother was diagnosed with multiple pulmonary emboli

and started on anticoagulants, immediately. After initiation of the correct diagnosis and
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medication, her symptoms, gradually, improved. However, she was one of the fortunate patients.

Hence, my purpose for wanting to investigate this problem using a fishbone diagram.

The cause of the problem was a delay in diagnosis and treatment of a deep vein

thrombosis. Early recognition and treatment may have prevented the development of a

pulmonary embolism. The causes are many, but do not necessarily fit into this case. My

problem statement, for the root-cause analysis, is, impaired gas exchange related to

thromboembolism traveling from her right lower leg into her lungs. Therefore, if the problem is

a pulmonary embolism, the categories that are often the causes of this could be, manpower,

communication barriers, team dynamics, methods used to diagnose, pre-existing medical

problems, and locality. I took her to a small local hospital that is not equipped for emergent

diagnosis. Initially, due to her symptoms, I thought it would be a simple pneumonia and that,

even, a small hospital would be adequate. After reviewing root-cause analysis, I realize that the

outcome could have been different. Thankfully, she was only a new miss.

Manpower was lower because it was a weekend and staffing was minimum. Because of

this, the patient ratio for each nurse was higher coupled with it being a busy night. Team

dynamics were not as strong, as a result. Also, there were communication barriers between the

nurse, physician, the patient; my mother, and the patients advocate, myself. While, in the

emergency department, I asked about the results of the blood test, the d-dimer, which would be

elevated if a P.E. was present. I was given false results, at that time. It was not until two days

later that a social worker, accidentally, disclosed the results while scheduling discharge planning.

A radiologist was not available to read the x-ray, much less, a cat scan. Typically, in a small

hospital, such as this, the emergency physician is sufficient to read radiographic films and cat

scans. However, it is not their specialty and, as a result, something could easily be missed. Not
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to mention, there was only one physician, in the department, this particular night. Also, the only

scan in the hospital was having repairs done but would be up and running the next day.

Collecting past medical history could have also been a method to consider the cause. Underlying

medical problems and recent surgery put her at a higher risk for developing a pulmonary

embolism. Also, recent travel and falling, several weeks prior, were never mentioned, until later.

Finally, I think the root cause of the problem, the pulmonary embolism, was an

undetected deep vein thrombosis. The root cause of the DVT, in my opinion, was the fall. It

resulted in severe bruising to her right lower leg combined with recent surgery, in which, she was

not prescribed prophylactic anticoagulants, in spite of, being on bed rest. Ultimately, all things

considered, the outcome was positive compared to what it could have been.
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References

Root Cause Analysis. (n.d.). Retrieved October 23, 2014, from Wikipedia:

http://en.m.wikipedia.org/wiki/Root_cause_analysis

Schmitt, E. R., & Burg, M. (2012). More than Just another Pulmonary Embolism. Western

Journal of Emergency Medicine, 13 (1), 98-99.

Torres-Macho, J., Mancebo-Plaza, A. B., Crespo-Gimenez, A., Sanz de Barros, M. R., Bibiano-

Guillen, C., & Fallos-Marti, R. (2013). Clinical Features of Patients inappropriately

undiagnosed of pulmonary embolism. The American Journal of Emergency Medicine,

32(10), 37.