ROOT CAUSE ANALYSIS

Root Cause Analysis

Priscilla Ambang
Bon Secours College of Nursing
Cynthia R. Woods, RN, MSN
Nursing 3206: Quality and Safety in Nursing Practice
October 24th 2016
Honor Code: “I Pledge”

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 ROOT CAUSE ANALYSIS

In the outpatient infusion center, or OPIC, patients are scheduled for a variety of reasons,

including lab work, iron infusions, blood transfusions, and primarily chemotherapy. Patients and

orders are received from a variety of practitioners and physicians, including nephrology,

neurology, behavioral health, hematology/oncology, endocrinology, etc. In the age of the

electronic health record, or EHR, communication between offices has greatly improved. Many of

these offices have access to the EHR where the can view a summary of the patients visit and

results of lab work. Research shows that “60 percent of physicians using EHRs reported that

their system facilitated communication among care team members.” (Hunt and Helwig, 2014)

However, some physician do not have this capability and will need to receive information about

the patients through traditional methods, such as fax. In the case of an unexpected and/or

emergent event, or a critical lab result, a phone call is made to the ordering physician.

Most recently, over the course of the past month or so, several of those latter physicians,

voiced a concern that they were not receiving information in a timely manner, or at all, especially

much needed lab work. They confirmed that in the event of a critical lab result, their office was

generally notified in one hour, as is policy. However, other labs, whether normal or abnormal,

were not being routed to their office, prompting research and eventually a call to the OPIC to

obtain the results. In one situation the physician had the capability to view the EMR but found it

difficult to access. Additionally, he couldn’t recall his access information, ie username and

password.

This lack of receipt was generally noted during a patient follow-up visit, resulting in an

inconvenience to all, but primarily the patient. Additionally, while the abnormal results may not

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be considered critical at the time, they could be suggestive of an impending event, which could

lead to a negative outcome for the patient, and all involved. An article in the American Journal of

Medicine attempted to shed light on the notification of lab results or the lack thereof in the

presence of an EHR. They concluded that there were still significant safety concerns, especially

in the outpatient setting. ( Singh, Thomas, Sittiq, Wilson, Khan, Peterson, 2010)

In order to determine how this was happening one must began asking why. Why did

these physicians not have access? Why were these physicians not contacted with results? Why

was there a delay in sending these results? Why weren’t the physicians accessing the system if

they had the capability? Why were the nurses not contacting the office with abnormal results?

By reviewing current processes and procedures and discussing with several of the OPIC

staff members, one could possibly determine how we could improve this communication

between offices, hence a root cause analysis. By using a root cause analysis, it allows

investigation from numerous perspectives. (Shaw and Elliott, 2012) The basic start of

questioning is why, and why again, and again, and so on, until the “absolute root cause” is

identified.

In the presence of an EHR, why did some physicians have access and others did not?

Physicians that fell under the umbrella of the organization were given access, however only a

select few other offices were given this capability. At the current time, there are no plans to

extend access to these offices. An alternative policy or method of contact needs to be developed

to address this specific population.

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When questioned, nursing reported that if the results were not available at the time

documentation was completed, whether a physician had access or not, they simply added a

comment stating “results pending.” Of those questioned, there was no consistency. Some made a

note to themselves to check for results during their next shift, while others simply expected the

offices to reach out to the OPIC for pending results. Unfortunately, the majority, pursued no

specific follow-up if the labs were not critical. However, it is to be noted nearly all surveyed

reported that if they noticed a significant abnormality, or change from previous results, though

not critical, a call was made to the ordering physician.

Depending on the lab work, processing times could be lengthy as with cultures, HIV

testing, Hepatitis, etc. The processing times were found to be in accordance with national

averages and there was no delinquency attributed to staff or processes. In the presence of a

lengthy result window, many of these were not being relayed to the physician. Physicians would

eventually contact the OPIC for result. This in itself could be quite alarming. One study

regarding abnormal lab notification noted a wide variety in percentages, depending on the result

and setting. This same study concluded that even missed cancer diagnosis, were the result of a

lack of follow-up in the event of lengthy result windows. (Callen, Westbrook, Georgiou, 2012)

On the other side of this issue were the physicians. Some reported though they had

access, they felt the system was somewhat difficult to navigate. Additionally due to limited use,

they routinely did not recall how to access the system, and forgotten login information. EHRs

have been widely applauded by many in healthcare on numerous levels. Despite the positive

reports, some physicians truly have not embraced the idea and don’t use it to its full capacity. Per

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some reports, there is all out resistance. (Ajami and Bagheri-Tadi, 2013) The organization needs

to ensure these offices receive adequate training and ongoing support.

Upon completion of the investigation, it appears the root cause was most likely attributed

to a lack of access, or ease of access to the EHR. It is suggested that those physicians with access

receive follow-up to ensure ease of access and notification of support systems. In regards to

those with no forthcoming access, a policy will need to be developed to ensure proper follow-up.

The current suggestion is a daily review of the patients seen in the previous 24 hours to ensure

completed labs were routed to physician via fax. This process would continue each day until the

patient’s record indicated final results for all labs drawn during their visit to the OPIC. Another

suggestion, is a communication log, with the patient’s initials, and date of service identifying

incomplete labs needing follow-up. A staff member, charge nurse or team leader could be

assigned this task each day to ensure communication to these offices. Communication is key in

any of these situations. Communication by a physician is what initiated a review of processes

and eventually will affect change and always support positive patient outcomes.

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Reference list

Hunt, D, & Helwig, A. 2014. Two questions made easier with an electronic health record.

Retrieved from https://www.healthit.gov/buzz-blog/electronic-health-and-medical-

records/questions-easier-electronic-health-record/

Singh, H., Thomas, E., Sittiq, D., Wilson, L., Espadas, D., Khan, M., Petersen, L. 2010.

Notification of abnormal lab test results in an electronic medical record: do any safety

concerns remain? American Journal of Medicine, 123(3): 238-244 doi:

10.1016/j.amjmed.2009.07.027

Shaw, P. & Elliot, C. (2012). Decreasing Risk Exposure. American Health Information

Management Association. Quality and Performance Improvement in Healthcare.

Callen, J., Westbrook, J., Georgiou, A., Li, J. (2012) Failure to follow-up Test Results for

Ambulatory patients: A systematic review. Journal of General Internal Medicine 27(10):

1334-1348. Doi 10.1007/s11606-011-1949-5

Ajami, S. & Bagheri-Tadi, Tayyebe. (2013). Barriers for adopting Electronic Health

Records (EHRs) by physicians. Acta Informatica Medica. 21(2): 129-134. Doi:

10.5455/aim.2013.21.129-134

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