Student Dissertation

Agency : Root Cause Analysis; Patient Identification Process; Error of Causes

Objective : 1. To analyze the patient identification process of the hospital and find out the challenges at each step of the process. 2. Department wise process analysis to identify the loop holes. 3. To identify errors in each of the process.

Background : Root cause analysis (RCA) is a method of problem solving that tries to identify the root causes of faults or problems. A root cause is a cause that once removed from the problem fault sequence, prevents the final undesirable event from recurring RCA practice solve problems by attempting to identify and correct the root causes of events, as opposed to simply addressing their symptoms. RCFA (Root Cause Failure Analysis) recognizes that complete prevention of recurrence by one corrective action is not always possible. Conversely, there may be several effective measures (methods) that address the root causes of a problem. Thus, RCA is an iterative process and a tool of continuous improvement. RCA is typically used as a reactive method of identifying event(s) causes, revealing problems and solving them. It can be used to forecast or predict probable events even before they occur.

Methodology : Study setting: Shree Siddhi Vinayak Hospital, Bhilwara (Rajasthan) Study type: Cross-sectional analytical study Study Duration:10th February to 30th April 2016. A Cross- sectional study was performed over a period of 3 months. Primary data was collected; Methods of data collection were direct observation and department wise semi-structured interviews. Secondary data was collected from hospital records, files, National International journals

Findings : On the basis of issues with high Criticality and high likelihood in the Root Cause analysis it is significant that due to preoccupancy of the staff wrong stickers were placed in patient’s file as a result X rays got misplaced and exchanged, also the housekeeping staff was involved in dispatch and receipt of films rather than the radiology staff that leads to errors in correct patient identification. IP stickers were issued with wrong details, wrong discharge slips were issued as a result wrong medications were offered to the patients. Moreover, UHID and the IPID that were used for the identification of the patient were too long and difficult to remember for the staff.

Recommendations : Errors in the process of care can result in injury. Sometimes the harm that patients experience is serious and sometimes people die therefore major errors like Patient’s name ID band must be checked before the administration of drugs, IP sticker must be placed on the vile before the collection of the blood sample, Nursing staff must be regularly updated and educated about the importance of patient identification and the complications related to the misidentification of the patient. Surprise audits must be conducted in order to check the method of patient identification.