Running head: ROOT CAUSE ANALYSIS 1

Root Cause Analysis

Angela Wetli

Bon Secours Memorial College of Nursing

3206

On my honor, I have neither given nor received aid on this assignment or test, and I pledge that

I am in compliance with the BSMCON Honor System.

Root Cause Analysis

After a patient has had a total knee replacement, there can be a buildup of scar tissue that

limits a patients range of motion. These patients have trouble with walking and have pain due to

the stiffness of the knee. One option that these patients have is to have a knee manipulation done

by the orthopedic surgeon. At St Francis Eastside this procedure is performed in our recovery

room unit with mild anesthesia and a femoral pain block to numb the leg for the procedure. The

surgeon will then manipulate the knee in order to break up the scar tissue that has been building

up in the knee. The pain block usually lasts for 12 to 18 hours after the procedure in order to

limit the patients pain. This is done on an outpatient basis and the patient goes home within an
hour after the procedure. The patient is taken to our discharge area after the procedure to get

dressed and use the restroom before going home. There have been multiple patients that

attempted to get up without a nurse or family member, and they have fallen as a result. A root

cause analysis will discuss the patient population that receives the manipulation procedure, the

patient education regarding the procedure, and the equipment and staff involved in discharging

the patient after the procedure. This will specify the improvements that need to be made to

prevent further patient falls.

The patient population that requires a manipulation after a total knee replacement are

likely an older population with limited strength. They have also been unable to perform the

recommended physical therapy and exercises following the surgery that would prevent the scar

tissue from forming and limiting the range of motion in the knee. In a study from 2009 a patient

population was monitored and it was found that In our study group, the relevant pre-operative

factors were present in a total of eight patients. These included three patients with high BMI and

diabetes, four patients with high BMI and one patient who was on long-term warfarin for atrial

fibrillation(Mohammed, Syed, & Ahmed, 2009). These patients are at a higher risk for falling

because of a higher body mass index and decreased upper body strength when using a walker

after the procedure to ambulate. A staff member should be present during the discharge process

in order to help the patient ambulate to the restroom and getting dressed. As the patient leaves to

go home, a staff member should then accompany them to the car in order to prevent falling.

The patient should begin to receive education regarding the procedure and the pain block

that will be administered as soon as the manipulation is recommended. The numbness and

weakness from the block usually lasts from 10-24 hours and occasionally greater than 24 hours

("Femoral nerve block," n.d.) The patient needs to be educated on standing up and use of the
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walker to prevent falls since the leg will be completely numb and not hold the patients weight.

The patients family should also be aware that the leg will be totally numb and the patient will

need help ambulating in the hospital to get dressed and then again when going into their home.

Instruction on proper use of the walker and good body mechanics are very important to prevent

falls. A patient care giver should remain with the patient during the entire discharge process after

the manipulation is performed to remind the patient and the family of proper technique and help

the patient with ambulating to the restroom and to the wheelchair for discharge. The Joint

Commission recommends creating awareness among staff, empowering patients to take an

active role in their own safety, and utilizing a "validated" fall risk assessment tool (Dupree,

2014). Even with extensive education, the patients might not be compliant and call for help or

ask a family member for help, therefore it is important for a hospital caregiver to remain with the

patient until discharge to the vehicle.

Staff education regarding the nerve block and the proper equipment to help the patient

ambulate are very important. Caregivers should be given proper education regarding how the

pain block works and the long term numbing effects on the patients leg. The patients will also be

given sedatives before the procedure, which can impair mobility. Videos and in-services from

the anesthesiologists regarding the procedure would be effective. Also the AHRQ recommends

educating the staff regarding the fact that patients with impaired gait or mobility will need

assistance with mobility during their hospital stay. All patients should have any needed assistive

devices, such as canes or walkers, in good repair at the bedside and within safe

reach.("Preventing falls in hospitals," 2013). Walkers should be in each discharge room so that

they are readily available. A staff member should escort the patient to the restroom and a hand

bar should be close to the toilet to help the patient sit down with support. The patient should be
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provided a wheelchair for discharge. The staff member should assist the patient into the vehicle

with proper body mechanics in order to prevent the patient from falling next to the car.

After multiple patient falls following knee manipulations, this root cause analysis showed

where our hospital could improve in order to prevent further falls. Root cause analysis (RCA) is

a structured method used to analyze serious adverse events. Initially developed to analyze

industrial accidents, RCA is widely deployed as an error analysis tool in health care.("Root

cause analysis," n.d.). Our analysis showed that we could prepare for the patient population that

is likely to receive a manipulation, we could educate the patients, family members and caregivers

taking care of these patients in the hospital, and we could provide adequate equipment and a staff

member to take care of the patient during discharge to prevent falling.

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References

Dupree, E. (2014). Taking a stand against falls. Retrieved from

http://www.jointcommission.org/jc_physician_blog/taking_a_stand_against_falls/

Mohammed, R., Syed, S., & Ahmed, N. (2009). Manipulation under anesthesia for stiffness

following knee arthroplasty. Annals royal college of surgeons of England, , 220-223.

http://dx.doi.org/http://dx.doi.org/10.1308%2F003588409X359321

Patient safety primers: Root cause analysis. (n.d.). Retrieved from

http://www.psnet.ahrq.gov/primer.aspx?primerID=10

Preventing falls in hospitals: A toolkit for improving quality of care. (2013). Retrieved from

http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtoolkit.pdf

Regional anesthesia techniques: femoral nerve block. (n.d.). Retrieved from

http://www2.massgeneral.org/ortho/ASCFemoralNerveBlock.htm
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