HA425 Unit 5 ED Walkout Root Cause Analysis Example

Two Hours and Fifty-Three Minutes, Then the Door: A Root Cause Analysis of One Composite Patient Who Left a Community Hospital Emergency Department Without Being Seen, Tracing the Walkout to a Staffing Template Nobody Had Compared With the Arrival Curve

[Student Name]

Purdue University Global

HA425: Operational Analysis and Quality Improvement

Unit 5 Root Cause Analysis

[Instructor Name]

[Date]

The patient, the evening and every count are composite and bracketed; clinical detail is limited to what the operations analysis needs, and no real event is described.

Scope and Method

The review follows the RCA2 approach, which asks teams to build a detailed timeline, write causal statements that link causes to the event, and choose actions ranked by strength, favoring system changes over training and reminders (National Patient Safety Foundation, 2015). The team included the emergency department nurse manager, a staff nurse, an evening provider, the patient experience lead and a quality analyst. The review is about the system, not individual blame.

Timeline

18:12: A [44]-year-old woman arrives with abdominal pain. 18:24: Triage assigns a mid-acuity level. Standing-order labs are not drawn because the triage nurse is covering two arrivals at once. 18:40: Placed in the waiting room; [17] others waiting. 19:00: A day nurse's shift ends and four rooms close as scheduled. [20] rooms remain staffed. 20:24: A repeat set of vital signs, due two hours after triage, is not done. 21:05: The patient leaves without telling staff. She is recorded as left without being seen, using the department's standard definition of that metric (Welch et al., 2011). 21:30: The charge nurse calls her; she reports she went to an urgent care center.

The First Explanation: A Busy Night

Staff said the department was simply busy. The team checked: [63] patients arrived between 11:00 and 21:00 that Tuesday, against a typical [62] for that weekday. Volume does not explain the event. If the night was ordinary, the long wait was ordinary too, which turns one walkout into a pattern built into how the department is staffed.

The Second Question: What Was Different About Capacity?

Nothing. The room closure at 19:00 happens every weekday. The capacity analysis had already shown that evening demand needs about [22] rooms while [20] are staffed after 19:00. The walkout was a predictable result of an everyday mismatch.

Contributing Factors

1. Staffing template: the twelve-hour nursing shifts start at 07:00 and 19:00, so the template drops a nurse at 19:00 whatever the arrival curve. Nobody had compared the template with arrivals by hour since the template was set [six] years ago.

2. Triage workload: one triage nurse in the evening cannot draw standing-order labs when two patients arrive together, so tests that could run during the wait do not.

3. Re-assessment: the two-hour vital sign re-check depends on the triage nurse, who is busiest exactly when re-checks are due.

4. Communication: the waiting room has no updates on expected wait, so patients cannot judge whether to stay.

Causal Statements

1. Because the nursing staffing template reduces staffed rooms at 19:00, when arrivals remain at their peak, room capacity falls below demand each weekday evening, which increases waiting room time and the likelihood that patients leave.

2. Because one triage nurse covers arrivals and re-checks during the evening peak, standing-order labs and re-assessments are often missed, which lengthens the visit and leaves waiting patients unmonitored.

3. Because patients receive no information about expected waits, they cannot make informed decisions, which increases the likelihood of leaving.

Actions Ranked by Strength

Stronger actions change the system; weaker ones depend on people remembering. Stronger:

1. Change the staffing template so one twelve-hour shift runs 11:00 to 23:00, keeping [24] rooms open through the evening peak.

2. Create a results-pending area so patients awaiting results free their rooms.

Intermediate:

3. Add a second triage nurse from 17:00 to 21:00 to draw standing-order labs and complete re-checks.

4. Display expected waits in the waiting room.

Weaker:

5. Remind triage nurses about the two-hour re-check.

What the Team Considered and Rejected

The team considered adding a sign asking waiting patients to tell staff before leaving. It was rejected as a weak action: it would improve the department's records but would not shorten the wait. The team also considered a policy requiring providers to see waiting patients in the hallway during the peak. It was rejected because hallway assessments lack privacy and equipment, and because they shift work without adding capacity.

Measures

Outcome: evening left-without-being-seen rate and median door-to-provider time for arrivals from 19:00 to 23:00. Process: percentage of re-checks done on time; standing-order labs drawn at triage. Balancing: morning door-to-provider time, since moving a shift later thins morning coverage.

Why Volume Is the Wrong Explanation

The word busy hides two different conditions: more patients than usual, or the usual number of patients with less capacity. Only the first is outside the department's control. Leaving without being seen is often linked to crowding and long waits in published reviews (Hoot & Aronsky, 2008). But crowding is not the same as high volume. A department can be crowded at ordinary volume if capacity drops at the wrong time, which is what happened here.

What the Patient Experienced

The patient waited nearly three hours without updates, without the labs that could have shortened her visit and without a re-check. She made a reasonable decision with the information she had. The analysis treats her departure as a signal of system failure, not a choice to criticize.

How Often This Happens

In October, [33] evening arrivals left without being seen, about one a day on weekdays. Each one is an event like this one, though most go unreviewed. The analysis therefore treats the composite Tuesday as a typical case of a daily pattern rather than an isolated failure.

Sharing the Findings

The team will present the analysis to evening staff, emphasizing that the cause is the template, not their work, and will ask staff to help design the shift change.

Follow-Up

The team will review the evening walkout rate monthly for six months after the actions begin and repeat the analysis if it does not fall. The quality committee will receive the results with the analysis attached.

Limits

The analysis follows one event and the evening pattern; it does not analyze admitted patients or weekend staffing, which may have other causes.

Conclusion

One walkout on an ordinary evening led to a cause hidden in plain sight: a staffing template that reduces rooms at the peak every weekday. The strongest actions change the template and free rooms, while weaker reminders alone would leave the pattern in place.

References

Hoot, N. R., & Aronsky, D. (2008). Systematic review of emergency department crowding: Causes, effects, and solutions. Annals of Emergency Medicine, 52(2), 126-136. https://doi.org/10.1016/j.annemergmed.2008.03.014

National Patient Safety Foundation. (2015). RCA2: Improving root cause analyses and actions to prevent harm. National Patient Safety Foundation.

Welch, S. J., Asplin, B. R., Stone-Griffith, S., Davidson, S. J., Augustine, J., & Schuur, J. (2011). Emergency department operational metrics, measures and definitions: Results of the second performance measures and benchmarking summit. Annals of Emergency Medicine, 58(1), 33-40. https://doi.org/10.1016/j.annemergmed.2010.08.040