NUR 531 Module 5 Root Cause Analysis Paper Example

Root Cause Analysis: Why a Hospital's Water Made a Patient Sick, and Which Fixes Will Hold

[Student Name]

Southern New Hampshire University

NUR 531: Interprofessional Leadership in Healthcare

Root Cause Analysis Paper

[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.

Root Cause Analysis: Why a Hospital's Water Made a Patient Sick, and Which Fixes Will Hold

The previous paper described a patient on 4 East who developed Legionnaires' disease on the twelfth day of a hospital stay and the actions taken in the first 72 hours. This paper reports the root cause analysis that followed. It uses the RCA2 approach, which steers teams away from asking who erred and toward asking what in the system allowed it, and which favors actions that change systems over those that rely on memory or vigilance (National Patient Safety Foundation [NPSF], 2015). The analysis found that the patient was harmed because a water management program had stopped operating, so a renovation, a valve adjustment and six closed rooms changed the unit's water without anyone assessing the risk, and it recommends physical and process changes that do not depend on people remembering.

Team and Method

The chief nursing officer chartered the analysis within 72 hours of the case. The team included the infection preventionist, the facilities director and a plumbing supervisor, a hospitalist, the oncology pharmacist, an environmental services manager, a patient safety specialist as facilitator and me as the nurse manager of 4 East. No one involved in the unit's direct care of the patient served as a member, though several were interviewed. The team met four times over five weeks. It reviewed the water management plan written in 2018, work orders from the previous two years, the renovation plan for the neighboring unit, temperature logs and the results of water sampling, and it walked the unit's plumbing with the facilities staff who maintain it.

Findings

Water samples from twelve outlets on 4 East grew Legionella pneumophila in three: the showers in two of the six rooms closed during the renovation and a faucet in an occupied room on the same branch of piping. Those six rooms had been closed for five months, and no work order had been issued to flush their showers or faucets. Hot water temperatures recorded at the unit's outlets ran several degrees below the minimum the hospital's plan set for distal outlets; temperatures at the water heater, the only point routinely logged, were within the plan's range. The team traced the drop to a mixing valve that had been adjusted during the renovation to reduce complaints of scalding water in the new unit, which shares a branch with 4 East. The water management team named in the 2018 plan had last met in 2021, when its chair retired, and had not been told about the renovation.

These findings match the patterns CDC investigators found in outbreaks: inadequate disinfectant, temperatures favorable to growth and failures of process, people, equipment and unmanaged change (Garrison et al., 2016).

Causal Statements

RCA2 asks teams to write causal statements that show cause and effect, avoid negative descriptors such as poor or inadequate, trace each human error to its preceding cause, tie each procedural deviation to its cause and recognize that failure to act is causal only when there was a duty to act (NPSF, 2015). The team agreed on five.

Table 1

Causal Statements Agreed by the Root Cause Analysis Team

No statement names an individual. The plumbing supervisor who adjusted the valve was solving a real scalding problem, and the unit staff had no reason to flush rooms nobody told them were at risk. Both acted reasonably inside a system that lacked the step that would have caught the hazard.

Actions Ranked by Strength

RCA2 sorts corrective actions into stronger, intermediate and weaker categories. Stronger actions change the physical environment, force the correct step or put leaders visibly in charge; weaker ones, such as training or a new policy, depend on people remembering (NPSF, 2015). Table 2 lists the team's actions in that order.

Table 2

Corrective Actions Ranked on the RCA2 Action Hierarchy

Note. Composite action plan.

The action plan answers each causal statement with at least one intermediate or stronger action. Education appears last and alone in the weaker category, because a reminder cannot keep water hot or flush a room nobody enters. The new requirement for water team review of construction reflects the federal expectation that hospitals assess where Legionella could grow and manage their water accordingly (Centers for Medicare & Medicaid Services [CMS], 2018), and the use of temperature control and flushing follows the control measures described in CDC's toolkit (Centers for Disease Control and Prevention [CDC], 2021).

Leading the Analysis

The analysis required nursing to lead a process in which most of the fixes belonged to other departments. Three practices helped. The team examined the building and the records together, so no department's account went unchallenged or unheard. Causal statements were drafted in the meeting, on a shared screen, so that everyone agreed to the wording. And the facilities director, whose department owned most of the stronger actions, presented them to executive leadership, which made the actions facilities' commitments rather than nursing's requests.

Conclusion

The patient on 4 East was harmed by a hospital water system that changed without anyone assessing the risk, because the team responsible for that assessment had stopped meeting. The five causal statements trace that failure through a renovation, a valve adjustment, unflushed rooms, missing temperature checks and an untested earlier case. The actions favor physical changes, automatic triggers and visible leadership over education. The next steps are a SWOT analysis of the water management program and a proactive assessment to find the next failure before it harms a patient.

References

Centers for Disease Control and Prevention. (2021). Developing a water management program to reduce Legionella growth and spread in buildings: A practical guide to implementing industry standards (Version 1.1). https://stacks.cdc.gov/view/cdc/114167

Centers for Medicare & Medicaid Services. (2018). Requirement to reduce Legionella risk in healthcare facility water systems to prevent cases and outbreaks of Legionnaires' disease (LD) (QSO-17-30, revised). https://www.cms.gov/medicare/provider-enrollment-and-certification/surveycertificationgeninfo/downloads/qso17-30-hospitalcah-nh-revised-.pdf

Garrison, L. E., Kunz, J. M., Cooley, L. A., Moore, M. R., Lucas, C., Schrag, S., Sarisky, J., & Whitney, C. G. (2016). Vital signs: Deficiencies in environmental control identified in outbreaks of Legionnaires' disease: North America, 2000-2014. Morbidity and Mortality Weekly Report, 65(22), 576-584. https://doi.org/10.15585/mmwr.mm6522e1

National Patient Safety Foundation. (2015). RCA2: Improving root cause analyses and actions to prevent harm. https://www.ihi.org/resources/tools/rca2-improving-root-cause-analyses-and-actions-prevent-harm