Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis "uses a team approach with emphasis on the system, as opposed to the individual, to accrue empirical data on what happened and why" (Balakrishnan et al, 2019, p. 911). 18-month-old Josie King was seeking help at a well known and highly rated hospital. Unable to advocate for herself, her mother was continuously at her side advocating for her daughter. Josie was fatally harmed by misuse of opioids and untreated dehydration ultimately leading to her death (Capella University, 2022). This sentinel event will be analyzed using root cause analysis, root causes will be explored, an evidenced based practice improvement plan will be discussed, and available resources that can have a positive impact on patient safety will be identified. Analysis of the Root Cause The sentinel event of the death of a child due to preventable medication error takes place at John Hopkins Hospital where Josie King and her family were seeking treatment for first- and second-degree burns. In January 2001 18-month-old Josie climbed into a hot bath and suffered burns over a portion of her body. Her family sought treatment for these burns at a highly rated hospital. Josie was progressing well and was moved to an intermediate care floor, her mother constantly at her side taking in the care being provided and asking questions. Josie's central line was removed for fear of infection and over the course of the week she was displaying signs of extreme thirst. Her mother was informed not to let her drink. Josie was sucking on the wash cloth during bath time to quench her thirst and she experienced episodes of her eyes rolling back in her head. Her mother advocating for her questioned two different nurses about this and asked for them to call the doctor and she was reassured that her vital signs were stable and Josie was fine. The next morning Josie's mother arrived to see her daughter in distress and