IHP 645 Module 6 Milestone Two Example

Milestone Two: Six Hours on 4 West, a Root Cause Analysis

[Student Name]

Southern New Hampshire University

IHP 645: Regulatory Compliance, Accreditation and Promoting a Patient Safety Culture

Module Six Milestone Two

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone Two: Six Hours on 4 West, a Root Cause Analysis

Milestone One found that Pinecrest Regional Medical Center's analysis of a recent sentinel event was incomplete. This milestone completes it. It describes the event, the team and methods, the timeline, the causes identified and the actions proposed, ranked by their likely strength, with measures to show whether they work.

The Event

A 68-year-old man was admitted to 4 West after an elective bowel resection. On his second night, beginning around 11:00 p.m., his heart rate rose from 92 to 128, his blood pressure fell from 124/76 to 94/58, his breathing quickened and he became confused. The nurse paged the covering surgical resident at 1:10 a.m. and again at 3:40 a.m. and was advised to give fluids and continue monitoring. A rapid response was called at 5:05 a.m. when he became unresponsive. He was found to have an anastomotic leak with septic shock, was transferred to intensive care and died two days later.

Why Failure to Rescue Matters

Ghaferi et al. (2009) compared hospitals with high and low mortality after major surgery and found that complication rates were similar; the difference lay in failure to rescue, the rate of death after a complication occurred. High-mortality hospitals were less successful at recognizing and responding to complications. This event fits that pattern exactly: the complication itself was not preventable with certainty, but the delay in recognizing and treating it was.

Team and Methods

The review team included a surgeon and a nurse from another unit, a hospitalist, a pharmacist, a patient safety specialist and a former patient advisor, with no one directly involved in the event. The team interviewed eight staff, reviewed the record and monitor data, walked the unit at night and built a cause-and-effect diagram, asking repeatedly why each step happened as it did. Its charter was to find system causes, not to judge individuals.

Timeline

The timeline shows four missed opportunities: vital signs at 11:00 p.m. that met sepsis screening criteria but were not scored, a first page at 1:10 a.m. that did not prompt a bedside evaluation, a second page at 3:40 a.m. that again resulted in phone advice and a period between 3:40 and 5:05 a.m. in which the nurse, caring for six patients, considered but did not call a rapid response.

Table 1. Timeline of the Event

Note. Composite reconstruction from records, monitor data and interviews.

Cause One: Monitoring Without Scoring

4 West recorded vital signs every four hours but had no early warning score to combine them into a single signal of risk, and the electronic record's sepsis screen was not active on surgical units. Each abnormal value was noticed, but no system translated the pattern into a mandatory response.

Cause Two: An Escalation Culture

Hospital policy allows anyone to call a rapid response, but interviews revealed an unwritten expectation on 4 West that nurses first obtain physician agreement. Two nurses described being criticized for calling without approval. The culture survey's 32% positive safety climate on 4 West reflects this pattern.

Cause Three: Night Staffing and Coverage

The nurse cared for six patients, above the unit's target of five, because of a call-out. One surgical resident covered three floors and about 110 patients overnight and was managing an emergency admission during both pages. There was no expectation that residents evaluate patients at the bedside after a second call about the same concern, and no clear route for escalating to the attending surgeon.

What Rapid Response Teams Can and Cannot Do

Chan et al. (2010) reviewed studies of rapid response teams and found that they were associated with a reduction in cardiopulmonary arrests outside intensive care units in adults, but not with a significant reduction in overall hospital mortality. Rapid response teams help only when they are called early. Pinecrest's team was available and effective once summoned; the failure lay upstream, in recognizing deterioration and triggering the call.

Root Cause Statements

The team agreed on three root cause statements. The absence of an early warning score with mandatory triggers allowed a deteriorating pattern to go without a required response. An unwritten norm requiring physician approval delayed rapid response activation. Overnight resident coverage and nurse assignments left no one with the time and authority to evaluate the patient at the bedside.

Ranking the Actions

Peerally et al. (2017) argued that root cause analyses in health care often produce weak actions, such as reminders and retraining, fail to follow up and can drift toward blame. The team therefore ranked actions by strength. Stronger actions change systems, such as automated triggers; intermediate actions standardize processes or add resources; weaker actions rely on education and policy alone.

Corrective Actions

The strongest action is an automated early warning score in the electronic record that pages the rapid response team directly when a threshold is crossed, without requiring nurse or physician approval. Intermediate actions include a rule that a second call about the same concern requires a bedside evaluation within thirty minutes or escalation to the attending, a night nurse float to protect assignments from call-outs and adding a second overnight surgical provider. Weaker, supporting actions include written reaffirmation that anyone may call a rapid response and simulation training on recognizing sepsis.

Table 2. Corrective Actions Ranked by Strength

Note. Composite action plan approved by the quality committee.

Measures

Outcome measures are failure-to-rescue deaths after surgery and cardiac arrests outside intensive care. Process measures are time from first early warning trigger to rapid response evaluation, the rate of rapid response activations on surgical floors and the share of second calls followed by bedside evaluation. The review team will report at 90 days and six months.

Conclusion

The patient's death followed a complication that could not be fully prevented but was recognized far too late. The causes lay in monitoring without scoring, a culture that delayed escalation and coverage stretched too thin. Actions that change systems, backed by measures and follow-up, give Pinecrest its best chance of rescuing the next patient.

References

Chan, P. S., Jain, R., Nallmothu, B. K., Berg, R. A., & Sasson, C. (2010). Rapid response teams: A systematic review and meta-analysis. Archives of Internal Medicine, 170(1), 18-26. https://doi.org/10.1001/archinternmed.2009.424

Ghaferi, A. A., Birkmeyer, J. D., & Dimick, J. B. (2009). Variation in hospital mortality associated with inpatient surgery. New England Journal of Medicine, 361(14), 1368-1375. https://doi.org/10.1056/NEJMsa0903048

Peerally, M. F., Carr, S., Waring, J., & Dixon-Woods, M. (2017). The problem with root cause analysis. BMJ Quality & Safety, 26(5), 417-422. https://doi.org/10.1136/bmjqs-2016-005511