HCS 456 Week 4 Risk Management Tools and Decision Making Example

Two Insulin Lists and One Kitchen Table: A Root Cause Analysis and a Failure Mode Analysis of the First Home Visit, and the Decisions That Followed

[Student Name]

University of Phoenix

HCS/456: Risk Management

Week 4 Assignment

[Instructor Name]

[Date]

The patient, the agency and the event details are composites written for a model paper; the methods come from the sources listed.

A composite 74-year-old retired carpenter went home from the hospital on a Thursday after a heart attack. On Saturday evening his daughter found him confused and sweating, and paramedics measured a blood sugar of 38. He had taken 40 units of long-acting insulin instead of the 20 prescribed at discharge. The home health nurse had visited Friday. The agency's risk manager led two analyses: a root cause analysis of this event and a failure mode analysis of the first home visit for every patient. This paper applies both tools and describes the decisions that followed.

Tool One: Root Cause Analysis

Root cause analysis looks back at an event to find why it happened. The agency followed the approach published by the National Patient Safety Foundation (2015), known as RCA2, which calls for a small team including someone with knowledge of the process and someone without, a review that starts within days, a focus on systems rather than individuals and actions ranked by strength.

The Timeline

The team, a nurse, a pharmacist, a quality specialist, the risk manager and a hospice social worker unfamiliar with home health intake, rebuilt the sequence. Wednesday: the hospital reduced his insulin from 40 to 20 units because he was eating less. Thursday: the discharge summary listed 20 units; his pharmacy bottle, filled a month earlier, still said 40. Friday: the nurse's first visit lasted 90 minutes, and she recorded the hospital list. She asked him to show her his medicines; he showed her pills but not his insulin pen, which was in the refrigerator. Saturday: he took his usual 40 units from habit and the old label.

Asking Why

Why did he take 40 units? He followed the old label and habit. Why was the old label not corrected? Refrigerated medicines were not part of the visit's medication review routine. Why did the nurse not reconcile against the pharmacy? The agency had no access to fill records, and the intake form asked for the hospital list only. Why was the dose change not taught? The discharge summary did not highlight changed doses, and the visit checklist did not ask about them.

Root Causes

Three root causes emerged: the first-visit process reviewed only the medicines patients chose to show, the agency lacked pharmacy fill data, and dose changes were not flagged or taught. The research explains why these gaps matter: Corbett et al. (2010) found at least one medication discrepancy in 94% of older patients discharged home, averaging 3.3 each. The nurse did what the form asked; the form asked the wrong question.

Ranking the Actions

RCA2 classifies actions by strength. Stronger actions change the system so errors are hard to make; weaker ones rely on memory and attention. The team proposed six actions: a new policy requiring full reconciliation, a weak action; retraining nurses, weak; a checklist item for refrigerated and injected medicines, intermediate; electronic access to pharmacy fill history for every patient, intermediate to strong; standardizing the intake form so it cannot be completed without entering the pharmacy list and every changed dose, a forcing function and strong; and a pharmacist phone review for high-risk medications within 24 hours, redundancy and intermediate.

Tool Two: Failure Mode Analysis

Failure mode analysis looks ahead at a process to find how it could fail before harm occurs. DeRosier et al. (2002) described the health care version built by the federal veterans health system's patient safety center: choose a process, assemble a team, draw the process, identify failure modes, score each by severity and probability and act on those with high hazard scores.

Mapping the First Visit

The team mapped eight steps: receive the referral, review the discharge summary, schedule the visit, gather the medicines in the home, compare them with the hospital list, compare with the pharmacy record, teach the patient and family, and document and report discrepancies.

Scoring Failure Modes

The team gave each failure mode two ratings from one to four, one for how bad its effect would be and one for how often it could happen, and multiplied them. The three highest were: medicines kept elsewhere in the home, such as insulin in the refrigerator or inhalers in a car, missed during review, hazard score 12; pharmacy record unavailable, 12; and changed doses not identified in the discharge summary, 9. Lower-scoring modes, such as scheduling delays, were monitored rather than acted on.

The Decisions

Leaders approved four actions. The intake form in the electronic record now requires a pharmacy fill list and a field for every changed dose before the visit can be closed. The agency subscribed to a pharmacy history service that shows fill records for most patients. Nurses use a room-by-room prompt, including the refrigerator, bathroom and bedside, to gather medicines. A pharmacist reviews every patient taking insulin, blood thinners or opioids by phone within 24 hours of the first visit. Retraining supports these changes but is not relied on alone.

Follow-Up and Measures

The director of clinical services owns the actions. Measures include the share of first visits with a completed pharmacy comparison, target 95% within three months; discrepancies found per patient; and medication-related readmissions or emergency visits within 30 days, reviewed monthly. The risk manager will audit 20 first-visit records a month for six months.

How the Tools Improved the Decision

Without the tools, the agency's first response had been to counsel the nurse and reissue the reconciliation policy. The root cause analysis showed that the process, not the nurse, failed, and the failure mode analysis showed where the next failure was likely. Together they redirected money toward a forcing function and pharmacy data rather than another memo.

Conclusion

A single insulin overdose, analyzed with root cause analysis, revealed three system causes. A failure mode analysis of the first visit found where similar harm could occur next. Ranking actions by strength and scoring failure modes by hazard led leaders to choose system changes with owners and measures, the kind of follow-up most likely to keep the event from happening again.

References

Corbett, C. F., Setter, S. M., Daratha, K. B., Neumiller, J. J., & Wood, L. D. (2010). Nurse identified hospital to home medication discrepancies: Implications for improving transitional care. Geriatric Nursing, 31(3), 188-196. https://doi.org/10.1016/j.gerinurse.2010.03.006

DeRosier, J., Stalhandske, E., Bagian, J. P., & Nudell, T. (2002). Using health care failure mode and effect analysis: The VA National Center for Patient Safety's prospective risk analysis system. The Joint Commission Journal on Quality Improvement, 28(5), 248-267. https://doi.org/10.1016/S1070-3241(02)28025-6

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