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Medical Error Under Root Cause Analysis


The flowchart (see Appendix A) is used to analyse all the events that took place in the Union Hospital Emergency Department that resulted in the patient in Case Study B to be harmed.


The root cause analysis (RCA) tool is used to establish factors that result in clinical mishaps. In this case, the RCA based on the timeline on the flowchart (see Appendix A), the “5 Whys” was used. The objective of the strategy is to underpin the root cause of a clinical error by making sure that all the “5 Whys” are effectively answered. According to Giai et al. (2017), the method amplifies the probability of recognizing the root cause of a medical error. In this regard, based on the Flowchart timeline and the “5 Whys”, two contributing factors and one causal factor were classified.

One of the contributing sources of error in the case study was the high degree of stress within the staff members as a result of the level of nurse enlistment within the hospital department at the time of the error. For instance, as noted in the case study, with a score of 25% as a positive rating among the staff, is it imperative that the rating was low, thus leading to a conclusion that the department was massively understaffed. As such, poor staffing often results in departmental stress because of burnout (Dyrbye et al., 2019). According to Dyrbye et al. (2019), poor clinical judgments and reduced hospital performance are a consequence of burnouts caused by understaffing. Coupled with the constant distress and agitation in the, along with the high level of tension among the nurses and the managing director, the medical error was prone to happen.

An institutional-based factor was also another contributing factor for the medical error. For instance, the hospital had no beds available, yet the doctor attempted to admit the patient to the hospital to perform chest tube correctional surgery. At last, the hospital had to conduct a transfer of the patient to Jefferson Memorial Hospital. Before the transfer, the hospital had a positive rating of 15% on transitions and handoffs thus were prone to errors during transfer situations, as described in the study. According to Gesensway (2018), poorly standardized transfer processes are often related to frustrations, hence medical errors. Therefore, the hospital should ensure collective responsibilities and enact policy changes for overall hospital performance.

Lack of effective communication is one of the major causal factors identified in the case study. Failure to communicate to the patient to sign the written consent forms is one of the several instances of poor communication in the case. Furthermore, a doctor’s or nursing “time out” was not conducted before the start of a procedure, a clear indication of ineffective communication. The process of ‘time out” is vital as it ensures that the right processes are followed (Jeong et al., 2017). As such, ineffective communication is shown to have resulted in the increased harm to the patient, especially the lack of transfer communication.

Patient Safety Strategies


Patient safety strategy should aim to address ineffective communication in the hospital. Inadequate communication was established to be the root cause of sentry activities in the U.S. (Burgener, 2017). As a recommendation to address the situation and avoid future medical errors in the hospital, the use of SBAR (Situation, Background, Assessment, and Recommendation) is hereby proposed. The tool is efficient in strengthening communication links between and among medical doctors and nursing staff. It was innovated to advance handover issues, thus was effective in improving patient safety (Muller et al., 2018). From the standardized questions formulated in SBAR, sharing of vital information of a patient is guaranteed among the healthcare providers. SBAR is a critical tool in creating a shift of change during medical transfers, and in this case, could have been used to deliver a particular report to the medical staff during the “time out” processes, thus reducing medical errors.

Patients and family members are integral members of a healthcare plan. In this case, engaging the patient and the families in the care plan based on the SBAR tool can be applied in such events as assigning a nurse to review the consent forms before being signed by the patient or the family proxy in cases where the patient mental capacity is compromised. If the patient has the mental capacity to sign such consent forms, the patient develops a clear comprehension of the medical procedures, thus giving them a say on what medical plan they want. According to Legg (2019), medical informed consent also allows patients to understand both the risk and benefits. Hence, certain medical procedures provide an individual with an opportunity to choose the care plan they want.


A quality improvement project can be sued to measure the impacts of applying SBAR in the Hospital. The measurement is also vital in increasing the knowledge about the use of SBAR and its positive effects in advancing effective communication among hospital caregivers. In this case, a standard audit can be conducted to evaluate each gaining of information with regards to the use of SBAR. Notably, the risk of falls concerning the use of SBAR in maintaining effective communication between healthcare providers can be identified and addressed immediately.

Moreover, to ensure that SBAR is effectively implemented in the hospital, a team leader can be designated for the SBAR to act as oversight to all the requirements of the usability of the SBAR. A simple medical campaign can also be performed and can include such activities as continuous medical education (CME), visual aids, and poster labelled SBAR, to ensure that teaching and understanding of the information about SBAR are universally known to healthcare members. Upon the completion of the sensitization of the SBAR, a measurement such as how the nurses report using the SBAR can be evaluated as a percentage to gauge if they are effectively used well.



Based on each particular federal state where a patient is undergoing treatments, obligatory or voluntary reporting of mishaps, medical errors, or other sentential actions is available. Compulsory reporting is needed in all adverse situations or errors that have led to harm, injury, or death. Conversely, voluntary reporting can only be allowed in events where a medical error leads to non-severe harm that can be reverted with a simple medical procedure. Therefore, the objective for enforced reporting is to ensure that the medical doctors are responsible for their actions, while voluntary reporting is necessary for the provision of data for advancing medical research that ensures prevention is done in future procedures. For instance, in New York, mandatory medical reporting was initiated in the year 1986 to report every case of patient death, malfunction of medical devices, or involuntary termination of services (Moskovitz, Sapadin & Guttenberg, 2020). In essence, admission o faults medical procedure is an important aspect of medical procedure as illustrated above.

Method and Preparation

The Code of Federal Regulations principle 42 contains all the public health guidelines and procedures for all hospitals. According to the guidelines, it is a requirement that all hospitals must institute a medical procedure with a possibility of a patient submitting their complaints to a particular hospital within a stipulated time frame of analysis and reaction (Electronic Code of Federal Regulations [E-CFR], 2018). Therefore, based on the described guidelines, the current case can apply the University of Michigan model based on three main statements (Agency for Healthcare Research and Quality [AHRQ], 2016). First, one should follow all the rules and conditions of a hospital to report the patient safety measures. Second, all events leading to medical errors should be inspected independently using peer review certified personnel in the related field. Third, the healthcare provider should communicate with the patient’s family and deliver a full revelation of all the injurious errors, illuminating why they happened.


Reporting of patient data is mandated in cultivating a culture of safety in the hospital organization. According to the Joint Commission (TJC), all hospitals are required to gather and monitor patients (The Joint Commission [TJC], 2018). TJC also necessitates all sentinel actions be revised by each hospital. In this case, a response team is required to reveal all the events that transpired in a medical error to the patients or family, this ensuring necessary support is accorded. Moreover, a notification is required by the leadership of the hospital to ascertain that immediate exploration of any mishaps is completed in due dates and the course of action taken.

Patient Safety Culture


A hospital-based survey is critical in comprehending the patient culture within a working hospital organization. Hospital Survey on Patient Safety Culture (HSOPS) is often performed to evaluate the safety of patients and the effectiveness of healthcare systems. It is also vital in ensuring that areas that require improvements are identified, and comparisons between healthcare-related departments are conducted (AHRQ, 2016). As such, the HSOPS has a user guide that describes that a survey should be conducted to every member including the subordinates because patient care requires multidisciplinary actions.


The outcome of a survey based on the events that happened in the Union Hospital Emergency Department can only result in a lackadaisical a patient safety culture. In the case study, almost all departments provided inadequate communication, poor patient transfer procedures, poor duty-related transitions, and handoffs. Furthermore, the hospital violated such policies as TJC guidelines and state laws. In this case, the medical staff’s failure to receive and necessitate informed consent from the patient could be regarded as a medical error with a possibility of legal redress.


Awareness and safety initiatives towards the patients during the treatment are critical strategies to reduce malfunctions in hospital departments. As a recommendation, the addition of the patient and family in the safety and awareness campaign correlates to accumulating more layers of defence mechanisms against medical errors. Particularly, the patient and family profile have one core role in an organization; the interest of ascertaining that appropriate care is provided to every member of a hospital setting. In this case, study, if at all there was a patient or family (third party), this could have provided their eye where an intervention of a near-miss could have been prevented.



TeamSTEPPS (TS) is an American-based strategy that has been established to elevate communication among healthcare providers. The strategy is sanctioned by the American Hospital Association (AHA) because of its proven capacity to reduce clinical adverse events (American Hospital Association [AHA], n.d.). This framework works by instituting the SBAR tool in allowing effective communication through clinical judgment skills acquisition. Using the same strategy, situational awareness is done among the staff to facilitate the transition in time-outs, handoffs, and debriefs, thus increasing staff mindfulness about a patient health condition, usage of medical devices, and collection of detailed clinical data necessary for patient safety and quality, hence reduction in injuries or unnecessary deaths.

Safer Patient Care

HSOPS promotes the patient safety culture in a healthcare organization. The approach is used to assess communication and teamwork models and the outcomes are shared among the medical staff to evaluate areas of improvement if any. Once the data is appraised, a team leader receives the feedback and collaborates with other experts to critique such areas as workforce staffing, leadership advancements, resources allocation, and overall patient culture. According to research by Giai et al. (2017), the HSOPS strategy was effectively used to develop a safer, quality, and appropriate culture in healthcare facility with affected by inadequate resources and understaffing. In this regard, it is imperative to suggest this method for future research concerning patient safety cultures in a hospital.


To understand and to evaluate if communication improved in the hospital upon perfuming the strategies described above, staff training, inspection results, and any medical errors should be measured and compared to data recorded before the implementation of the communication strategy. Based on the records found, if a variance is greater than before, and then the existence of inadequate communication is detected. In such cases, the patient survey data is re-evaluated and a survey among the staff is conducted to ascertain the areas of weakness. However, with a positive result with regards to inspection outcomes, adequate communication is predicted to been embraced as a culture, thus maintenance or additional training is recommended.


American Hospital Association (n.d.). Implementation of TeamSTEPPS to improve communication, patient outcomes and reduce clinical errors. Web.

Agency for Healthcare Research and Quality. (2016). Hospital Survey on Patient Safety Culture: User Guide. Web.

Burgener, A. (2017). Enhancing communication to improve patient safety and to increase patient satisfaction. The Health Manager, 36(3), 238-243. Web.

Dyrbye, L. N., Shanafelt, T. D., Johnson, P. O., Johnson, L. A., Satele, D., & West, C. P. (2019). A cross-sectional study exploring the relationship between burnout, absenteeism, and job performance among American nurses. BMC Nnursing, 18(1), 1-8. Web.

Electronic Code of Federal Regulations. (2018). Electronic Code of Federal Regulations. Web.

Gesensway, D. (2018). The many problems with transfers. Web.

Giai, J., Boussat, B., Occelli, P., Gandon, G., Seigneurin, A., Michel, P., & François P. (2017). Hospital survey on patient safety culture (HSOPS): Variability of scoring strategies. International Journal for Quality in Health Care, 29(5), 685-692. Web.

Jeong, E. J., Chung, H. S., Choi, J. Y., Kim, I. S., Hong, S. H., Yoo, K. S.,… & Cho, Y. S. (2017). Development of simulation‐based learning programme for improving adherence to time‐out protocol on high‐risk invasive procedures outside of operating room. International Journal of Nursing Practice, 23(3), e12529. Web.

Legg, T. (2019). What you need to know about informed consent. Web.

Moskovitz, J., Sapadin, J., & Guttenberg, M. (2020). Interfacility ambulance transport of mental health patients. Journal of the American College of Emergency Physicians Open, 1(3), 173-182. Web.

Muller, M., Jurgens, J., Redaelli, M., Klingberg, K., Hautz, W., & Stock, S. (2018). Impact of the communication and hand-off tool SBAR on patient safety: A systematic review. BMJ Journal, 8(8), 1-10. Web.

Ruhomauly, Z., Betts, K., Jayne-Coupe, K., Karanfilian, L., Szekely, M., Rolwani, A., McCay, J. & Jaffry, Z. (2019, June 1). Improving the quality of handover: Implementing SBAR. Future Healthcare Journal, 6(2), 54. Web.

The Joint Commission. (2018). The Joint Commission E-edition. Web.

Appendix A

A summary of the order of events that transpired before Paul’s treatment and during admittances at Union Hospital Emergency Department, Treatment, and then Death.
Figure 1: A summary of the order of events that transpired before Paul’s treatment and during admittances at Union Hospital Emergency Department, Treatment, and then Death.
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