The nurses in the Emergency Department of your hospital have recently suffered a
ID: 375620 • Letter: T
Question
The nurses in the Emergency Department of your hospital have recently suffered an increase of injuries from assault patients and family members. One nurse had to be hospitalized with head injuries after the most recent assault. Upon interview in the ICU, her co-workers inform you that the security guard in the ED has been less visible of late. They have complained to their nurse manger, to no avail. Using the resources and references provided in this chapter, create a plan for a root cause analysis of this latest incident and an injury prevention plan.
Explanation / Answer
The incident is a medium criticality incident and hence we would prepare an RCA and try to find out the root cause for the same. Generally we prepare a RCA when an incident of high or medium criticality occurs or an incident of recurring nature happens, thereby risking the regular operations.
Now in this case the observation is that the security guard is less visible but it could be erroneous and might not solve the problem. Hence we would create a root cause analysis in a format as shown below.
General information:
Incident Title: Severe assault by patient on employees
Site of incident : Emergency dept. of the Hospital
Trigger for RCA : Recurring or high severity incident (Both)
Dept. or people affected: Dept. Nurses and other patients
Chronology of events: Date Time Event Witnesses
Define the problem: Increase in the number of assaults by patients and their families on hospital staff
Impact to patient, employees, general public: Severe injuries, Threat to life and material damage
Investigation details and presumptive causes: We can use either of the methods such as 5 Whys, Fish-bone diagram to determine the causes and the effects during the incident. In this case let us use the 5 Whys method where we would ask 5 times why to get to the root cause of the incident.
Why was the assault not controlled physically – Because the nurses are physically weaker than the assaulter and the security guard was not present nearby?
Why was the security guard not present nearby – Security guard had gone to escort another patient
Why the security guard did went to escort another patient – Because there was only one security guard on duty in that shift and other patient was very violent and the nurses needed immediate help
Why was only one security guard in that shift- because the shift roster has been prepared to manage with inadequate number of personnel?
Causes and are they contributing factor or root cause:
Corrective action to restore services:
Recommendation and Improvement action plan:
1) More number of Security personnel to be assigned to the emergency dept.
2) Nurses would not attend or move the patients in the absence of security guards.
Approvals and attestation from Dept HoD and action owners:
Additional information (Images, verbatim, Audio recordings etc):