Question

LaTonya, a young woman with diabetes, dies after being admitted for a kidney infection. What might an RCA NOT be able to uncover?

(A) The medical resident caring for her did not know the appropriate antibiotics for this type of infection.
(B) There are 23 steps between ordering an antibiotic and administering it on the unit.
(C) The new electronic medical system does not have a mechanism to flag "stat" antibiotics for pharmacy.
(D) Fatigue among residents is contributing to unsafe care.

Answer 1

An RCA may not reveal how fatigue among residents contributes to unsafe care since it is a subjective factor more difficult to quantify and does not leave a direct trail of evidence.

Step-by-step explanation:

An RCA (Root Cause Analysis) may not be able to uncover (D) Fatigue among residents is contributing to unsafe care. While an RCA can identify systemic issues like lack of knowledge or procedural complexities, it is not always effective in identifying and measuring subjective factors, such as fatigue among healthcare professionals, which do not leave a concrete trail of evidence.

By examining an RCA, we can pinpoint issues such as a medical resident's lack of knowledge about antibiotics (A), the number of steps required to administer an antibiotic (B), and issues with the electronic medical system (C). However, resident fatigue is a more nebulous factor that can significantly affect patient care without being as easily traceable or quantifiable within the hospital's systems or processes for RCA.