Root-Cause Analysis
Root-cause analysis (RCA) allows the researchers to discover the event’s fundamental flaws and prevent their repetition. RCA is a systematic approach to discovering the causes of sentinels to set preventative measures (Charles et al., 2016). RCA gives a perspective on the Heimlich value orientation error leading to radiographic tension pneumothorax (Broder et al., 2015). The paper gives an overview and an RCA of the case supported by evidence-based and best-practice strategies to create a safety improvement plan from existing organizational resources.
Analysis of the Root Cause
The case occurred with a 20-year-old man with autism who reported dyspnea at the emergency department. The patient denied any occurrence of trauma or fever before the examination and required a chest radiography. Fourteen catheters were placed, but air started escaping from the catheter after the chest tube’s insertion. The chest drainage unit was used with a Heimlich valve to stop the air leak. A chest X-ray (CXR) was performed immediately, and 2.5 hours later it showed a proper positioning of the pleural catheter, but the intended orientation of the Heimlich valve was reversed. It resulted in the interval enlargement of the pneumothorax and development of tension pneumothorax, including complete lung collapse, lucent hemithorax, deep sulcus sign, depressed hemidiaphragm, and mediastinal shift (Broder et al., 2015). The physicians noticed the issue and reoriented the Heimlich valve. After the correction of the valve, a CXR demonstrated the resolution of the pneumothorax and other complications. The error was then disclosed to the patient and his family to manage the possible implications.

The technical failure of the equipment used was not the only reason for the event. It was one of the root causes as the device instructions and design allowed improper insertion and contributed to the error. The device lacked a process control function or testing for correct orientation in the instructions. However, human errors certainly played a defining role in the event. The medical providers lacked practical skills and knowledge about the valve. The perceptive and cognitive errors made the providers mistake the Heimlich valve for a simple connector because of its resemblance to the adaptor. The setting for the event also comprised the environmental factors that affected the medical procedure. The condition was presented urgently as the patient addressed the emergency department. The factor was still controllable as the patient’s condition was stable and did not require an immediate procedure. The staff could have used more time to investigate the device functioning or select a more familiar device.

The root causes of the event also include communication factors such as both oral and written communication problems. The directions for the Heimlich valve were not transparently communicated through labels or instructions and in the medical team. The right policy for valve insertion should have been formed to prevent the event from occurring. The medical staff should have strictly followed the guidelines and communicated the arising problems to the team instead of risking the patient’s health. The poor communication between the team members and improper device instructions contributed to the patient’s injury.

Application of Evidence-Based Strategies
The evidence of certain factors having a direct effect leading to a sentinel event or other medication errors is necessary for determining the best practice strategies. According to the Joint Commission (2020) Patient Safety Goals, several goals to assist healthcare institutions were developed to ensure safer health practice for both patients and providers. They provide evidence-based goals to create a safer environment for medical institutions.

Communication failures or errors of emission between the medical workers are considered the most common cause of medical failures in about 30% of the cases (Umberfield et al., 2019). The following failures are divided into information failures in about 60% of the cases and the lack of shared understanding in 40% (Umberfield et al., 2019). Since communication problems are the most common cause of medical errors, it is imperative to improve the communication channels and means between staff members to minimize information failures and lack of understanding.

The technical and medication errors remain the other prevalent evidence for sentinel events. On average, a patient is subject to at least one medical error a day with varying statics among hospitals, considering at least a quarter of them are preventable (Umberfield et al., 2019). To prevent the possible implications from technical and medication errors, the best practice strategies suggest avoiding abbreviation lists, using a computerized entry system to avoid human factor in the possible mistake, and comparing patients’ medication orders with other medications through medication reconciliation to avoid omissions, dosing or technical errors and duplications.
Improvement Plan with Evidence-Based and Best-Practice Strategies
The sentinel case’s main focus points are improved education, user instructions, and device design. First, the root cause of human knowledge-based problems requires a policy for mandatory education and established guidelines. The staff training can at least minimize possible errors if not eliminate altogether. In the era of innovation, the internet and data-based technology should also be implemented to ensure patient safety.

The policy needs to be based on the case’s precedent and contain specific guidelines. Technical failures can be prevented using explicit written instruction, especially for the rarely-used or new medical devices. The medication and device design should be improved and labeled for better usability and medication safety (Joint Commission, 2020). Moreover, all medical devices should be overviewed in three classes of devices based on risk. Class 1 does not require prior FDA review, class 2 requires non-clinical testing, and class 3 devices requires to determine if there is reasonable assurance of safety.

Moreover, education and device designs should be combined and applied in practical emergency scenarios. They should be engineered to provide the staff with the medical practice of using particular devices and enhancing their cognition and teamwork skills. Such an emergency simulation allows a reduction of the risk of device misuse and battles the root-cause of communication problems (Joint Commission, 2020). The following plan should be carefully reviewed and implemented step-by-step with the policy introduces within a week and scenarios within a month.

Existing Organizational Resources
The plan’s implementation does not require a lot of additional resources other than labels and time dedicated to planning the training. The primary source positively impacting the number of potential mistakes is labels that provide clear and direct instructions. Technical failure requires writing additional instructions and putting labels on the devices and medication. The secondary resource that can only have a more significant impact in the long-term if done regularly is time for training and in-service sessions. The human problem cannot be fully resolved within the scope of human cognition, but training can decrease the possible number of mistakes. The guidelines do not require extra resources but paper or online access. The staff training should be mandatory and require additional medicine and device supplies to provide materials for all the staff members to practice, adding extra cost for the equipment. Overall, the current organizational resources would suffice for the plan implementation.

Conclusion
Identifying the existing mistakes is essential in the medical field as the root cause is not always apparent. Various person or environmental factors can lead to irreversible consequences, including the death of the patient. Examining these mistakes in the specific circumstances allows for creating guidelines for medical institutions and preventing them in the future. An in-depth analysis of the mistake and correlating factors is essential in creating a plan for further actions.

References
Broder, J. S., Fox, J. W., Milne, J., Theiling, B. J., & White, A. (2015). Heimlich valve orientation error leading to radiographic tension pneumothorax: Analysis of an error and a call for education, device redesign and regulatory action. Emergency Medicine Journal, 33(4), 260–267. Web.

Charles, R., Hood, B., & Derosier, J.M. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: A review. Patient Safety in Surgery, 10(20). Web.