The first part is to review the attached Root Cause Analysis Sample Scenario. After your review, you will need to perform and document the RCA steps from the text. This portion of the assignment should be about 2-3 pages in length. You do not need to explore every possible cause and solution, but you should be thorough and hit the major issues.

The second part of the assignment is to create a cause and effect diagram (aka an Ishikawa diagram or a fishbone diagram). There are a number of websites where templates of diagrams are available for free in Excel and Word formats.

You are expected to perform some research on the procedures and medical conditions listed in the sample in order to fully analyze the problem. You are also expected to cite those sources with a high degree of frequency. The general rule of thumb is if it is not known to the average person, it needs to be cited. This means that most of your sentences containing factual statements will have a citation.



(SAMPLE SCENARIO)

Executive Summary

This example examines an actual case of hospital re-admittance which includeda second surgery. While recovering from the second surgery, the patientcontracted a clostridium difficile infection which extended his stay for an extra twodays. The re-admittance was complicated by the fact that the patient had to betransported by air due to the fact that he lives 150 miles away from the hospital.This is an interesting case because it involves a highly experienced surgeon andwell-respected hospital facility.

Cause and Effect Summary

On 8/30/2016 a male in his mid-seventies went to the hospital to have what wasinitially thought to be a dime-sized hernia repaired. Given the fact that this patienttreats kidney failure with peritoneal dialysis, a process that involves filling andsubsequently draining the abdomen with fluid, the surgical team decided to placethe hernia repair mesh between the inner abdominal lining and the layer ofabdominal muscles. This would keep the mesh from coming in contact with thedialysis fluid, thereby lessoning the risk of infection or other complications.Once the operation was begun, the damaged area turned out to be much larger.The plan did not change – however the area of the repair was much larger. Thesurgical team thought this to be the best possible plan. And there have been nopast complications.The operation was a success. The patient was sent to post-op, and thenadmitted for overnight observation. The next day, after receiving hemodialysis,the patient was released. The patient was strongly advocating for release. Thereis systemic pressure on hospitals from insurance companies to limit stays. Afamily member then drove the patient 150 miles back to his home.Over the next two days, it was determined that the patient was not recovering asexpected. He had no appetite, felt nauseous, was bloated/distended, and had notmoved his bowels since before surgery. The following morning, he was feelingextremely ill and asked to be taken to the emergency room of the local hospital(different from where the surgery was performed). The local hospital examinedhim and ordered an X-ray. The X-ray was inconclusive, so they ordered a CTscan. The CT scan revealed a suspected blockage in the bowel. They were incontact with the surgeon who performed the hernia operation, who recommended that he be admitted and treated until the blockage resolved –process theyestimated would take a few days.After further examination of the CT film, it was determined that the patient’s initialhernia operation had failed. The stitches inside the abdomen had pulled out dueto the integrity of the abdominal tissue. This patient’s abdomen wascompromised by the process of peritoneal dialysis. Additional stresses werepresent because the patient is also obese and he has had numerous pastsurgeries. A portion of his small bowel had become occluded (trapped) inside thearea where the stiches had torn out. This small bowel occlusion was causing thedistressing symptoms.

The local healthcare team decided that they could not repair the hernia locally.So they decided to send him back to the surgeon that conducted the originalsurgery. This required an air ambulance.The patient was immediately sent to the OR upon arrival. The hernia was againrepaired, but this time using a much larger piece of mesh that covered most ofthe abdominal wall. The patient was then admitted to the hospital. After a fewdays, the patient developed diarrhea. The surgical team thought that this wasdue to the quantity of stool softeners prescribed. But when it did not clear up aftera few days, a family member requested a test for clostridium difficile. The familymember requested this test because his mother died from hospital-acquiredclostridium difficile in 2007.The test confirmed that the patient had contracted clostridium difficile. Therefore,his stay was extended by two days.

Answer rating: 100% (QA)

To begin the root cause analysis we need to identify the problem or issue at hand In this case the problem is the readmittance of the patient to the hospital after the initial hernia surgery There are ... View the full answer