What are the primary causes for CAUTI’s based on your experience of working through a root cause analysis?
Case Study Part II Worksheet
Section 4 Discussion Question:
What are the primary causes for CAUTI’s based on your experience of working through a root cause analysis?
Section 4 Assignment 1:
Create a Root Cause Analysis as described in section IV and attach it to this worksheet
Section 4 Assignment 2:
Select one of the root causes identified in assignment 1. Select one small part of the cause that can be changed and map out a PDSA cycle for the change. Attach your map to this worksheet
Section 4 Discussion Question:
Consider barriers to the PDSA cycle that you have created. List at least one barrier and discuss a method that the team can use to overcome this barrier.
SECTION IV BACKGROUND: CLARIFYING THE PROBLEM
The intent of this section is to work through the causative factors to fully understand the clinical problem. The focus
is to use a root cause analysis approach to examine the big picture and pull out the factors that contribute to the
problem.
In this section, you will use information provided from previous sections of the case study and your research to
create a root cause analysis. If needed, create scripts from the perspective of the various stakeholders who might be
involved with the process being investigated to illustrate the various perspectives.
Use the Healthcare Quality Improvement Partnership’s Root Cause Analysis for Clinical Audit guide (accessible at
www.hqip.org.uk/resources/using-root-cause-analysis-techniques-in-clinical-audit/) to guide the students through a
root cause analysis. Complete the cause–effect or fishbone diagram. A resource that includes a fillable template for
creating a cause–effect diagram can be accessed through the Institute for Healthcare Improvement (a free account
is required, accessible at www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx).
Chapter 12 Patient Safety includes an example of a root cause analysis.
The clinical nurse specialist (CNS) decides to work through a root cause analysis and use a cause–effect
diagram (fishbone diagram) with the team to identify potential causes for catheter-associated urinary tract
infections (CAUTIs). You work with the CNS to complete this activity with the team.
SECTION V BACKGROUND: PLANNING FOR CHANGE The intent of this section is to create a preliminary plan for action by using the PLAN-DO-STUDY-ACT model as
outlined in chapter 13.
The team decides to use the Plan-Do-Study-Act model to determine small tests of change that can be undertaken to
improve CAUTI’s in the patients the team cares for. You work with the team to develop a map of the PDSA model.
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