Child Abduction

Analysis of Key Components

RCA: Child Abduction

Please note that the root cause analysis and action plan must show evidence of an analysis within the key components as outlined on the root cause analysis matrix for the specific type of event. An area on the matrix that may not have an identified process breakdown should still be summarized to determine that the component was evaluated.

Brief description of event

Briefly summarize the circumstances surrounding the occurrence including the patient outcome (e.g., death, loss of function).

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Who participated in the analysis?

Please include a list of all team members that participated in the analysis by position and title. Please DO NOT include any names!

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When did the event occur?

Include the date and time the event took place.

 September 14, Thursday at 12:30pm

What area/service was impacted?

Include the full variety of services impacted by the event.

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What are the steps in the process, as designed? (Flow Diagram(s))

The organization may provide a Flow Diagram(s) of the steps in the process involving the occurrence. The organization may also list the key steps involved in the specific processes relating to the event. Ask–are all issues in the flow addressed? Suggestions are outlined below.

This is how the process currently works.

 

 

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Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.

 

 

 

What human factors were relevant to the event?

Evaluate the role of human performance factors that may have contributed to an error.

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Parent Registers Child

Parent and Child taken to pre-op areas by RN and prepared for surgery (pre-op assessment done and consent signed)

Parent can accompany child to door of OR suite

Post op, child transferred to recovery area

Once stabilized, parent and child reunited

Discharge teaching done and child discharged with parents once recovered

 

 

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Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.

How could equipment performance affect the outcome?

List the various equipment utilized for that patient during the healthcare stay. To assist in evaluating these processes consider the following: Were bio-med checks done and up-to-date? Was the equipment where it was supposed to be? Why or why not? Was staff in-serviced on equipment? How long ago? How frequently is the equipment used? Were alarms, displays, and controls identifiable and/or operating properly? Is the equipment set up and performing in accordance with the manufacturer’s recommendations? Were there equipment recalls that were not addressed? Was equipment designed to accomplish its intended purpose? Were equipment parts defective? Was there a report to another agency regarding equipment defect (FDA, etc)?

 No equipment issues were involved in this event.

What controllable factors directly affected the outcome?

Identify factors that may have contributed to the event that the organization has the ability to change by making process improvement changes.

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Were there uncontrollable external factors?

Uncontrollable external factors are those factors that the organization cannot change that contribute to a breakdown in internal processes. An organization should not be willing to assign many issues to this category. Although a factor may be beyond the organization’s control, the organization may be able to minimize the factor’s effect on patients.

 Father coming to see daughter (not under organization’s control)

What other areas or services are impacted?

List all other areas that have the potential for a similar event to occur. This will assist in implementing risk reduction strategies in other pertinent high-risk areas.

 Inpatient units

 Any ancillary/clinical department that may separate parent from pediatric patient

To what degree is staff properly qualified and currently competent for their responsibilities?

Include all staff present, not just those that were determined to be involved with the event. Do not overlook physicians and allied health practitioners/mid-levels. Determine if staff was formally trained to perform the specific duties or tasks involved in the event. Was the training adequate? Was staff qualified to use the equipment? Were competencies documented? Had procedures and equipment been reviewed to ensure a good match between people and tasks performed? Was there agency staff that may not have been familiar with procedures/equipment? Was float staff from another area assisting with lack of orientation to the unit they floated to? Was the individual new and performing a function that they were not oriented/trained/competent in performing? Was staff oriented to the organization and department specific policies/procedures?

 

 

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Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.

 No process in place at the time of incident to provide guidance to staff to directly prevent such an incident

 Staff had been appropriately oriented to the department/organization and did not have any performance issues.

How did actual staffing compare with ideal levels?

Was there appropriate staffing at the time of the event to address the required workload? Keep in mind if it was a weekend, change of shift, holiday, break time. Document the actual staffing in area of occurrence versus planned staffing according to the staffing model. Explain any variation; higher or lower staffing.

 Pre-op: Staffing model requires four RNs and one unit secretary that is shared with post-op side. Actual staffing was three RNs which resulted in pre-op nurses prepping additional patients than usual.

 Post-op: Staffing model requires four RNs with the shared unit secretary. Actual staffing was three RNs.

What are the plans for dealing with contingencies? What would reduce effective staffing levels?

Summarize current plans in place to deal with staffing deficiencies.

 Plans are in place to use float pool nurses, contact part-time staff for extra hours, or reassign staff from other units.

How has staff performance in the relevant processes been assessed? When was this last performed?

Consider staff performance relative to the specific processes associated with the event.

 NA—No process in place at the time of incident to provide guidance to staff to directly prevent such an incident

How can orientation and in-service training be improved?

Was all staff oriented to the job responsibilities, organization, and policies and procedures regarding safety, security, hazardous materials, emergency, equipment, life-safety, treatments, and procedures? Are policies revised/updated, evidence based, and readily available? Have policies or procedures changed without providing additional training? Was a new policy developed and staff training conducted? Do float staff or agency staff receive training within the areas they are assigned? Is this documented?

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To what degree is all information available when needed?

Was information from various patient assessments completed, shared, and accessed by members of the treatment team as required by policy? Was the patient correctly identified? Was the documentation clear and did it provide an adequate summary of the patient’s condition, treatment, and response to treatment?

 

 

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Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.

Was the level of automation appropriate? Identify what information systems were utilized during patient care.

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To what degree is communication among participants adequate?

Look at this content to cover verbal and lack of verbal/written communication(s).

 Physician to….

 Nurse to….

 Tech to….

 Pharmacist to….

 Hierarchical issues….

 Cultural issues….

And any other combination you can find during your investigation.

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To what degree was the physical environment appropriate for the processes being carried out?

Look closely at the environment the patient was in or was transferred to/from. Spaces, privacy, safety, and ease of access are a few items to consider. Was work performed under adverse conditions (hot, humid, improper lighting, cramped, noise, construction projects)? Had there been environmental risk assessments conducted? Did the work environment meet current codes, specifications, and regulations? Was the work environment appropriate to support the function it was being used for?

 NA—Physical environment did not play role in incident

What emergency and failure mode responses have been planned and tested?

Had appropriate safety evaluations and disaster drills been conducted? Had provisions been planned and available to support a breakdown in operations?

 “Code Pink” drills are done sporadically and not on routine basis

To what degree is the culture conducive to risk identification and reduction?

Did the overall culture of the facility encourage or welcome change, suggestions, and warnings from staff regarding risky situations or problematic areas? Does management establish methods to identify areas of risk or access employee suggestions for change? Are changes implemented in a timely manner?

 A member of the Senior Leadership group, including the CEO, participates in meetings related to serious adverse events.

 

 

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Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.

 Senior Leadership and department management encourage staff to bring opportunities and suggestions forward that would improve patient care and the work environment.

 Senior leadership and department management all are active in patient safety rounds and encourage open discussion of patient safety issues among staff.

What are the barriers to communication of potential risk factors?

What is your organization doing to break down barriers to effect change? Has the organization identified barriers to effective communication among caregivers? If there are no barriers, what have you done and how do you know it has been successful? Be specific.

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To what degree is the prevention of adverse outcomes communicated as a high priority?

Explain leadership’s role and how it is put into practice, provide examples.

 A confidential suggestion box and hotline have been established to report high-risk issues and each of these are read and evaluated by the Patient Safety Officer. Corrective actions are taken on a regular basis.

 “Patient Safety” is one of the organization’s values.

Was there a literature search done?

List all sources of literature accessed to complete the analysis and action plan. Literature may be accessed to assist in analyzing the event to determine process breakdowns and/or when developing actions once the root causes have been identified to assist in developing best practice recommendations for changing current practice.

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