Exercise 1
Objective: To practice addressing the questions in The Joint Commission RCA tool.
Instructions:
• Read the following case scenario.
• Follow the instructions at the end of the case.
Case Study:
The letter in this case study is adapted with permission from Trina Bingham (2005), master’s in nursing student at Duke University School of Nursing.
You are the risk manager of a tertiary care hospital and have just received the following letter from a patient who was recently discharged from your facility.
Dear Risk Manager,
Last month, I had surgery at your hospital. I was supposed to have a short laparoscopic surgery with a discharge by lunch, but it turned into an open surgery with complications. This led to a 4-day hospital stay and discharge with a Foley catheter. Overall, my hospital stay was OK, but I had a situation when the call bell was broken. It was during the night, and I was alone. I needed pain meds. I kept ringing the call bell and no one answered. I used my phone to call the switchboard and no one answered. I didn’t want to yell. My IV began beeping (to be honest I kinked the tubing to make it beep), but no one came with that noise either. Eventually the certified nursing assistant (CNA) came to routinely check my vitals and she got a nurse for me. They switched call bells, but apparently there was an electrical problem, and the call bell couldn’t be fixed until the next day when maintenance was working. The CNA told me to “holler if I needed anything” as she walked out closing the door. I was so mad, but by this time, the IV pain med was working and I was dozing off. I reported the situation again on day shift and spoke to the director of nursing and the quality assurance manager. Upon discharge, I included this dangerous and unethical situation on my patient satisfaction survey. But I have to wonder, when these data are combined with all the other data, if the situation looks insignificant. For me, it worked out OK. All I needed was pain medicine, but what if I had needed help for something more serious? Depending on the layout of satisfaction and quality of care survey results, this situation could look very minor. For all I know, my dissatisfaction was under the heading “dissatisfied with room.”
I am writing to you because I have not heard from the director of nursing or the quality assurance manager about what they have done to fix the problems. I believe it is important that you hear my complaint so hopefully other patients will not have to go through the terrible experience that I did.
To fix the problems described in this patient’s letter, you realize you must first understand the root causes of the problems. Although this situation did not result in a sentinel event, you realize that it could have and decide to conduct an RCA.
Brainstorm possible responses to the RCA questions in Exhibit 9.10.

Root Cause Analysis