| 26 | THE JOURNAL OF LEGAL NURSE CONSULTING

FEATURE

WHAT IS A ROOT CAUSE
ANALYSIS?
The Joint Commission (2015) defines
root cause analysis (RCA) as “a pro-
cess for identifying the basic or causal
factor(s) underlying variation in perfor-
mance. Variation in performance can
(and often does) produce unexpected

and undesired adverse outcomes” (p. 1).
Ultimately, RCAs are used to determine
why an unexpected or unintended out-
come occurred and “to identify system
vulnerabilities so that they can be elim-
inated or mitigated” (National Patient
Safety Foundation, 2015, para. 4). By
using RCAs to evaluate the events, haz-
ards, and vulnerabilities in their systems

of care, organizations and individuals
can gain an understanding of what hap-
pened and why and then identify actions
to prevent a recurrence. A root cause
analysis helps healthcare organizations
to better understand what circumstances
led to the undesirable outcome or near
miss, what safety rules were violated,
and where individual providers and

Root Cause Analysis: A Pediatric
Case Study
Katherine Haney, MSN, RN-BC

A root cause analysis (RCA) is a retrospective, structured investigation of an adverse event, near miss,
or sentinel event. By using RCAs to evaluate the events, hazards, and vulnerabilities in their systems
of care, organizations and individuals can gain an understanding of what happened and why and then
identify actions to prevent a recurrence. A root cause analysis helps healthcare organizations to better
understand what circumstances led to an undesirable outcome or near miss, what safety rules were
violated, and where individual providers and the organization as a whole failed. Adverse events in
healthcare come from a mix of active failures, latent conditions, and contributory factors.

Keywords: Root cause analysis, system breakdown, process error, pediatrics, risk management

ISSN 2470-6248 | VOLUME 31 | ISSUE 4 | WINTER 2020 | 27 |

the organization as a whole failed. It
is important to note RCAs generally
focus on organization-level system and
process failures, not on individual-level
performance failures “since individual
performance is a symptom of larger
systems-based issues” (National Patient
Safety Foundation, 2015, para. 4).

Mapping out events in a chronological
manner is one way to review the care
provided. However, in RCA methodol-
ogy, events are grouped together based
on categories. This allows different
insight into what exactly occurred and
why. One main advantage to group-
ing events into categories is it clearly
demonstrates what failures occurred at
the system and organizational level that
contributed to the adverse outcome,
near miss, or harm to a patient. Adverse
events in health care almost never occur
because of one, singular cause. They are
typically a combination of active failures
and latent conditions that align and slip
through any safety mechanisms in place
(The Joint Commission, 2015). Active
failures are “errors occurring at the point
of interface between humans and a com-
plex system” such as an electronic health
record software program or an auto-
mated medication dispensing system
(Agency for Healthcare Research and
Quality, 2019, para. 1). Latent condi-
tions are “the hidden problems within
health care systems that contribute to
adverse events,” e.g., no defined stan-
dard workflow (Agency for Healthcare
Research and Quality, 2019, para. 1).
This systems approach “is one of the
most widely used retrospective methods
for detecting safety hazards” in health-
care organizations across the country
(Agency for Healthcare Research and
Quality, 2019, para. 1).

HOW IS AN RCA
PERFORMED?
In a high reliability, patient safe-
ty-focused organization, RCAs are
performed by a team made up of
various members of leadership, includ-

ing representatives from Quality, Risk
Management, Nursing, and ancillary
departments as well as ad hoc members
based on the type of event and where
it occurred. Additionally, members of
the care team with personal knowledge
of the processes and systems involved
in the event under investigation should
also participate. Root cause analyses
performed by the facility are typical-
ly peer review protected (and thus
non-discoverable) during litigation.

There are four steps to performing a
root cause analysis.

1. Identify what happened to the patient.
2. Determine what should have

happened.
3. Determine the causes. Causes are

categorized into six different groups,
which will be discussed further
below: communication, training,
fatigue/scheduling, environment/
equipment, rules/policies/procedures
and barriers. The RCA team
methodically reviews each category
to determine the root causes and
contributing factors. Root causes are
“the underlying process and system
issues” identified by analyzing the
contributing factors, “the situations,
circumstances or conditions that
increased the likelihood of the event”
(Centers for Medicare and Medicaid
Services, n.d.).

4. Develop causal statements. These
statements explain how the
contributory factors brought about
the adverse outcome.

To better understand these steps, consid-
er the following fictitious case scenario.

WHAT HAPPENED?
Liam is an eight-year-old, right-hand
dominant male who is brought into
the county emergency department
after collapsing on the baseball field.
It is a hot day in the middle of sum-
mer, and his parents report he did not
break much for water during the soccer
game. Liam is difficult to arouse, has
dry mucous membranes, and a general
ill appearance. His lab results show
severe dehydration, and the registered
nurse (RN) starts an intravenous (IV)
infusion of five percent dextrose and
25 percent normal saline, plus 20 mEq
per liter of potassium in his right hand.
Liam’s mental status starts to improve
over the next few hours, and he is
conversing with his parents. He tells his
nurse his hand hurts where the IV is
running. The nurse explains the med-
icine they are giving may have a slight
burn feeling. When the medication is
complete, the RN switches him over to
normal saline per orders. The RN sees
his right hand is blistered, tense, and
discolored. He has a decreased radi-
al pulse, and capillary refill is greater
than three seconds. Unfortunately, the
infiltrate site progresses and results in
necrosis to the tissue and major loss of
function. Liam is no longer able to use
his right hand for writing, throwing a
ball, and activities of daily living.

WHAT SHOULD HAVE
HAPPENED?
A thorough review of the medical
records revealed the RN did not cor-
rectly place a large bore IV in a large
vein above the wrist as directed in the

A root cause analysis helps healthcare
organizations to better understand what
circumstances led to the undesirable
outcome or near miss…

| 28 | THE JOURNAL OF LEGAL NURSE CONSULTING

FEATURE

ment had been performed, the RN may
have been able to identify the infiltrate
sooner and intervene, thereby reducing
the risk of tissue necrosis and loss of
function. This is a failure of the RN to
assess the site of pain that was communi-
cated by the patient.

Training: This category asks, “Was
the staff training adequate?,” “Were
the results of training monitored over
time?,” and “Did the organization
provide adequate training programs

for staff with the intent of them
performing their tasks without

errors?” (National Patient Safety
Foundation, 2015, p. 32). In

the case mentioned, the RCA
team requested education
documentation from the
organization regarding IV
infiltrations, including the
actual education module/
content, number of learners

who have taken the module
and when, competency testing

scores, etc. In reviewing this
information, the RCA team noted

up-to-date, good quality content
but noticed a high number of learners
took the module in the recent past.
This may suggest the organization
was having an increase in IV infiltra-
tions and was attempting to reactively
(rather than proactively) educate staff
regarding prevention, recognition,
and treatment. This is a failure of the
organization to enforce its education/
training requirements and ensure its RNs
met competency before an adverse event
occurred. The content and quality of the
educational materials was good, but
the education and competency testing
were not executed the way the organiza-
tion intended.

Fatigue/scheduling: For this category,
the RCA team considers questions such
as “Did scheduling allow personnel
to have adequate sleep?,” “Was fatigue
properly anticipated?,” and “Were there
sufficient staff on hand for the patient

organization’s policy for the administra-
tion of caustic medication. Additionally,
the IV site, skin, and tolerance were not
assessed every two hours as required.
Lastly, when the RN notified the
emergency department physician of the
infiltrate, a vascular or plastic surgery
consult was not placed as outlined in
the organization’s policy.

workload at the time?” (National
Patient Safety Foundation, 2015, p. 32).
Looking at the emergency department
census for the shift in question, the
RCA team discovered it was a very busy
Saturday afternoon. This particular
nurse had three other patients (includ-
ing a myocardial infarction patient)
while caring for Liam. The RN was
working a 12-hour shift (the second one
in a row) with a higher than average and
complex patient load, increasing the chanc-
es an error would be made or a policy and
procedure not followed.

Equipment/Environment: This cat-
egory asks the RCA team to focus on
questions such as “Was there a docu-
mented safety review performed on the
equipment provided?” and “Was there
adequate equipment to perform the
work process?” (National Patient Safety
Foundation, 2015, p. 33). In this fic-
tional scenario, the RCA team asked for
the preventative maintenance log as well
as the audit trail for the IV pump that
was used to infuse the medication. A
review of these documents revealed the
organization followed its own require-
ments for scheduled quality checks and
the pump performed as programmed to
deliver the drug at the appropriate rate.
No deviations from standards within
the equipment category were found.

Questions to consider in this case from
the environmental perspective include
where were the room locations of the
RN’s other assigned patients and was
the RN having to traverse the entire
department to see all of these patients
or were they placed in adjacent rooms
from each other. A copy of the emergen-
cy department’s floor plan was requested
and showed all assigned patients were
within close proximity of each other
except for the myocardial infarction
patient who was placed in the trauma
bay across the department from Liam.
Because the nurse had to care for patients
in two separate areas of the department,
this took away from time the RN could

WHAT WERE THE CAUSES,
AND HOW DID THEY
CONTRIBUTE TO THE
OUTCOME (CAUSAL
STATEMENTS)?
Communication: This category asks
questions like “Was communication
between staff adequate?” and “Was a
‘readback’ or confirmation message
utilized?” (National Patient Safety
Foundation, 2015, p. 31-32). In the case
scenario, the RN documented Liam’s
complaints of pain at the IV site and
the education provided to him and his
family regarding the side effects of a
potassium IV infusion. Unfortunately,
Liam’s complaint of pain to the RN
did not prompt the RN to perform an
assessment of the IV site. If an assess-

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have been assessing and intervening with
the infiltrated IV.

Rules/Policies/Procedures: This
category focuses on questions such as
“Were there written policies and proce-
dures that addressed the work processes
related to the adverse event?,” “Were
these policies and procedures consistent
with state and national guidelines?,”
and “Were the relevant policies actually
used on a day-to-day basis?” (National
Patient Safety Foundation, 2015, p. 34).
Upon reviewing the organization’s pol-
icy and procedure for IV infiltrations,
the RCA team learned the provider is
responsible for consulting wound care,
vascular, and plastic surgery specialties
when an IV infiltration has occurred
and caused damage. In comparison,
Liam’s medical records showed only
wound care was consulted after identi-
fication of the injury. The wound care
RN assessed Liam and, at that time,
spoke with the emergency department
physician about the need for additional
consults. This resulted in a five-hour
delay of specialty care. The Medical
Staff Rules, Regulations, and Bylaws
for this organization state independent-
ly-contracted providers (such as the
emergency department physician) are
required to follow the policies and pro-
cedures outlined by the hospital. This is
a failure of the organization to ensure its
policies are followed by all members of the
care team. Because of this breakdown on
a system level, care was delayed resulting
in loss of function to Liam’s hand.

Barriers: Lastly, it is important to assess
what barriers and controls were involved
in an adverse event. Questions to consid-
er include, “Were these barriers designed
to protect patients, staff, equipment,
or the environment?” and “Had these
barriers been evaluated for reliability?”
(National Patient Safety Foundation,
2015, p. 34). In this case scenario, when
the RN scanned the IV solution to hang
it, the organization’s barcode medication
administration software program gen-

erated a pop-up alert in the electronic
medical record advising this was a caus-
tic medication. The alert reminded the
RN of the potential for serious tissue
injury with the medication. Unfortu-
nately, the RN dismissed this reminder
and did not use it as a tool to help with
the assessment process. While there is
value in this built-in safety barrier, it is
only as good as the human interacting
with it. This is a failure of the RN to heed
the alert, initiate interventions to reduce
the risk posed by administering a caustic
medication, and provide additional assess-
ment in light of this risk.

SUMMARY
In this case study, Liam suffered an IV
extravasation of potassium which led
to necrosis and loss of function of his
dominant right hand. A thorough root
cause analysis identified several areas
of opportunity for the organization.
Clearly defining action items to improve
the system or processes and identifying
which stakeholder is responsible for
each action is the best way to minimize
the chance of this type of harm happen-
ing again. First, nursing at this facility
needs reeducation around communica-
tion and reassessment when a patient
verbalizes pain and discomfort. Reed-
ucation should also include steps to
take to prevent an IV extravasation as
well as appropriate interventions once
one is recognized – as already outlined
in the facility’s existing policy. Nursing
should also be reminded the electronic
alerts and barriers are there to prevent
patient harm and should not be quickly
dismissed. Second, the facility should
focus on enforcing compliance with
education. By ensuring all required staff
complete assigned learnings, admin-
istration can further sort out whether
this is truly a lack of education issue or
a behavioral compliance issue. Next, the
facility should look at nurse-to-patient
ratios, how to better balance patient
acuity in each nurse’s assignment, and
ways to ensure each nurse’s patients

are in close proximity. This would have
prevented the RN from having several
high acuity patients at the same time
during the shift in different areas of
the department. Once the action items
have been completed, the RCA team
should schedule random audits on the
process throughout the year to ensure
action items have been addressed and
overall compliance has increased. By
periodically evaluating and analyzing
the effectiveness of the RCA action
items, the facility can ensure the RCA
was productive and meaningful and
can also continue to reduce the risk of
patient harm.

REFERENCES:
Agency for Healthcare Research and Quality.
(2019). Root cause analysis. https://psnet.ahrq.
gov/primer/root-cause-analysis

Centers for Medicare and Medicaid Services.
(n.d.). Guidance for performing root
cause analysis (RCA) with performance
improvement projects (PIPs). https://www.
cms.gov/Medicare/Provider-Enrollment-
and-Certification/QAPI/Downloads/
GuidanceforRCA.pdf

National Patient Safety Foundation. (2015).
RCA2: Improving root cause analyses and
actions to prevent harm. Institute for Healthcare
Improvement. http://www.ihi.org/resources/
Pages/Tools/RCA2-Improving-Root-Cause-
Analyses-and-Actions-to-Prevent-Harm.aspx.

The Joint Commission. (2015). Root cause
analysis in health care: Tools and techniques
(5th ed.). Joint Commission Resources.
https://www.jcrinc.com/-/media/deprecated-
unorganized/imported-assets/jcr/
default-folders/items/ebrca15samplepdf.pdf.

Katie Haney is a masters
prepared, licensed and
board-certified Registered
Nurse in the state of
California with a background
in Emergency Room nursing

and expertise in Quality and Risk Manage-
ment. She currently manages the Risk &
Safety Program for a 350-bed acute care
hospital in Southern California. Katie
frequently serves as an expert witness for
root cause analysis, risk and quality issues.

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