A Root Cause Investigation

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A root cause analysis (RCA) is a structured retrospective investigation that identifies the problems or causes leading to an adverse event (Reid & Smyth‐Renshaw, 2012). An RCA is structured in to several logical components. Firstly, identification of the adverse incident is required (Boyd, 2015; Nicolini, Waring, & Mengis, 2011; Reid & Smyth‐Renshaw, 2012). Following the identification of the event, an investigation in to the adverse incidentwas commenced by collecting the facts of the event, examining the causational factors and providing a written report to any recommendations to prevent the incident from occurring in the future (Boyd, 2015; Mengis & Nicolini, 2010; Nicolini et al., 2011). This essay will critically analyse the investigation

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Root Cause Analysis Paper

Root cause analysis is the process that helps to identify the factors that contributed to the adverse effect or other noted incident (Wachter, 2012). It is a helpful process that can assist in avoiding making the same errors with another patient. Root cause analysis is a vital component of the investigation of the incident at hand. The scenario presented in this case study was that of a patient name mix up resulting in the wrong procedure for the wrong patient. These women's names were very similar…

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Forensic Engineering: Fractography

studies the what causes the accident to occur, or evidence to identify criminals. Studying fractography in ceramics and glasses is similar to that of metals, using SEM or ESEM performed in low vacuum. Fracture surfaces are especially important for finding information of the origin, cause, and effect of the defect or accident. Surface features such as hachures reveal the origin of the cracks, and once the origin is found, information of the cause can be drawn such as for example, if the cause was a bullet…

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Police Brutality In Civil Protests

Police brutality has recently been the cause of many civil protests and outrage from the citizens. Police brutality is the unwarranted excessive use of force by law enforcement officials. Police brutality, which represents a pressing social issue distinguished by the unwarranted excessive force by law enforcement officials, is an issue that needs to be solved in order for society to move forward. This essay examines the victims of police brutality, the causes and a solution to help society move past…

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Business: Occupational Safety and Health and Personal Protective Equipment Essay

companies use the form that documents the original discovery of a hazard to track its correction. Hazard correction information can be noted on an inspection report next to the hazard description. Employee reports of hazards and reports of accident investigation should provide space for notations about hazard correction. Frequently, companies will computerize their hazard tracking system which can be as simple as adding a few items to an existing database, such as work order tracking. Preventive Maintenance…

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Research Investigation On Osmosis

4. Discuss the experiment and relate it to a real life organism 5.16. Plants use osmosis to absorb the nutrients required to sustain themselves from the water in the soil, they do this by using their roots which has a cell wall as well as a plasma membrane. The cell wall is a strong and rigid structure that is used by the cell to create osmotic pressure within the cell. This allows the plants to contain high amounts of water pressure which also helps…

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Essay about Accreditation Audit: Raft Task 1

Root cause investigation. Stahel, Mehler, Clarke and Varnell (2009), tell us that “wrong site and wrong patient procedures have been defined as "never-events" which are theoretically 100% preventable and thus should never occur”. They maintain that even with the…

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Hydroponics: Plant and Calcium Nitrate Essay

soluble for the plant to be able to absorb the nutrients through the root system. Nutrients are provided by the use of mineral salts, which can be either naturally derived or manmade. They are purified and processed so that they are in a form in which plants can obtain the nutrients found within these mineral salts. As well as this, it must too be water soluble for the plant to be able to absorb the nutrients through the root system. (Mason, 2009) Relevant Hydroponic Equations Most hydroponic experiments…

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Aids Paper

Doctors are baffled; they have no idea what could be making these people susceptible to the Pneumocystis carinii. More investigation reveals that all individuals who die of this, and similar opportunistic diseases, have a severely compromised immune status. Many of the people have a T-cell count of zero. The story then moves into the grass-roots method of epidemiological investigation into the issue. CDC specialists begin traveling the streets of major cities, such as New York and San Francisco in an…

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Root Cause Analysis

not. This process helps to make learning more effective, resulting in a reduction in illness burden and an increase in the efficiency of care. During root cause analysis, the learner plays a crucial role as they are not afraid to hypothesise, question, or challenge assumptions (Lucas and Nacer, 2015; cited in the Open University, 2024). Root cause analysis involves a series of questions aimed at learning and improving. Some of the questions that are asked include: What caused the fracture? Who was…

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Serco Group plc 2 Essay

service contracts with the government. Serco has agreed to repay over £68m as retribution. The Serious Fraud Office (SFO) opened a criminal investigation into the outsourcing company in late 2013 and is still investigating the scandal.2 Since then, the government has received £68 million from Serco, including VAT, and costs incurred from the investigation. 2013 and 2014 are looking like the toughest years for the company in 25 years. Profits have collapsed by 62%, more than 400 employees have…

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