Sentinel Event Analysis Using Root Cause Analysis
Step 1: Choose a Sentinel Event
- Hospital-acquired infection leading to death
Step 2: Analyze the Event Using the RCA Framework
1. Brief Summary of the Event: A 70 year old female patient was admitted to the medical-
surgical unit at Lakewood Medical Center. She had history of a stroke that left her with right-
sided weakness and urinary incontinence. She now had a trip and fall at home, and her
daughter brought her to the hospital for evaluation. Imaging done in the ER revealed a right-
sided femur fracture. She was scheduled for orthopedic surgery in the morning. The provider
requested an indwelling foley catheter be placed prior to the procedure and to aid with
comfort. The surgery was successful, but the patient remained in significant pain
postoperatively and was bedridden. The Foley catheter was not removed and remained in
place for seven days. On the evening of day 7, the patient began showing signs of urinary
tract infection. She was experiencing mild confusion, low-grade fever, and cloudy urine. The
nurse decided to get orders for a urine culture, which on day 9 came back positive for E.coli.
At this time the patient went septic, she was hypotensive and had a fever of 104. Sepsis
protocol was initiated; however aggressive fluids and antibiotics did not work. The patient
died from multi-organ failure on day 11 and this was determined a sentinel event due to
preventable measures. After chart review, no documentation of catheter care or assessments
was found.
2. Identify the Root Causes
a. What were the contributing factors?
- The contributing factors were the length of time the foley catheter remained in place
and the possible cleanliness of the catheter. Foleys should be cleaned with CHG
, Sentinel Event Analysis Using Root Cause Analysis
wipes daily and documented. Foleys should also be assessed daily, and nurses should
document needs assessments that determine if a catheter is still necessary.
b. Consider human, environmental, communication, and systems-level issues.
- Absent documentation is a human error. There should always be documentation for
Foley catheter assessments. This could also be related to a communication error
between employees caring for this patient. For example, it is possible that both the
nurse and tech assumed the other would clean the catheter and due to lack of
communication it never got done by either. I also see this as a system error.
Employees should be properly trained in Foley care and documentation.
3. Propose Corrective Actions
a. What could have been done differently?
- The catheter could’ve been removed much earlier to prevent infection. Hospital
guidelines recommend daily evaluation of catheter necessity and removal if no longer
appropriate (Patel, 2023). CHG wipes should have been used daily, and
documentation should have reflected catheter cleaning/care. Better nurse-nurse
communication, collaboration, and delegation may have changed the outcome.
b. Suggest at least two specific system-level improvements to reduce risk.
- Implement an automatic EHR Foley Care Checklist: This would start with an
indwelling catheter insertion checklist. It would require two nurses to sign off and
would go through the steps on properly inserting a foley catheter. The check-list
would focus on hygiene and aseptic technique (Whitaker, 2023). This system would
also cover daily documentation prompts for Foley catheter assessments. It would
Step 1: Choose a Sentinel Event
- Hospital-acquired infection leading to death
Step 2: Analyze the Event Using the RCA Framework
1. Brief Summary of the Event: A 70 year old female patient was admitted to the medical-
surgical unit at Lakewood Medical Center. She had history of a stroke that left her with right-
sided weakness and urinary incontinence. She now had a trip and fall at home, and her
daughter brought her to the hospital for evaluation. Imaging done in the ER revealed a right-
sided femur fracture. She was scheduled for orthopedic surgery in the morning. The provider
requested an indwelling foley catheter be placed prior to the procedure and to aid with
comfort. The surgery was successful, but the patient remained in significant pain
postoperatively and was bedridden. The Foley catheter was not removed and remained in
place for seven days. On the evening of day 7, the patient began showing signs of urinary
tract infection. She was experiencing mild confusion, low-grade fever, and cloudy urine. The
nurse decided to get orders for a urine culture, which on day 9 came back positive for E.coli.
At this time the patient went septic, she was hypotensive and had a fever of 104. Sepsis
protocol was initiated; however aggressive fluids and antibiotics did not work. The patient
died from multi-organ failure on day 11 and this was determined a sentinel event due to
preventable measures. After chart review, no documentation of catheter care or assessments
was found.
2. Identify the Root Causes
a. What were the contributing factors?
- The contributing factors were the length of time the foley catheter remained in place
and the possible cleanliness of the catheter. Foleys should be cleaned with CHG
, Sentinel Event Analysis Using Root Cause Analysis
wipes daily and documented. Foleys should also be assessed daily, and nurses should
document needs assessments that determine if a catheter is still necessary.
b. Consider human, environmental, communication, and systems-level issues.
- Absent documentation is a human error. There should always be documentation for
Foley catheter assessments. This could also be related to a communication error
between employees caring for this patient. For example, it is possible that both the
nurse and tech assumed the other would clean the catheter and due to lack of
communication it never got done by either. I also see this as a system error.
Employees should be properly trained in Foley care and documentation.
3. Propose Corrective Actions
a. What could have been done differently?
- The catheter could’ve been removed much earlier to prevent infection. Hospital
guidelines recommend daily evaluation of catheter necessity and removal if no longer
appropriate (Patel, 2023). CHG wipes should have been used daily, and
documentation should have reflected catheter cleaning/care. Better nurse-nurse
communication, collaboration, and delegation may have changed the outcome.
b. Suggest at least two specific system-level improvements to reduce risk.
- Implement an automatic EHR Foley Care Checklist: This would start with an
indwelling catheter insertion checklist. It would require two nurses to sign off and
would go through the steps on properly inserting a foley catheter. The check-list
would focus on hygiene and aseptic technique (Whitaker, 2023). This system would
also cover daily documentation prompts for Foley catheter assessments. It would
