Examples Of Root Cause Analysis

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RTT Task 2 The provided scenario gives an account of a busy emergency department with competent staff, and the multiple errors that led up to the most severe error possible in healthcare, unnecessary death of a patient. A root cause analysis (RCA) can be utilized to help understand the systems at fault within the facility so that improvements can be determined and implemented to prevent any future occurrences (Cherry, 456). RCAs focus on systems rather than blaming individuals involved, therefore they are only appropriate in cases where there has been no willful negligence or criminal acts (Huber & Ogrinc, 2014). The overall purpose of RCAs is to find out the causes of the adverse event and determine how to keep similar errors from …show more content…
A change to the work environment could possibly take place with the addition of more RN staff or support staff to assist when the RN is unable to leave the bedside. The nursing staff could brainstorm on time management, possibly the RN or a different sedation trained RN could recover the patient at the bedside while completing charting and other computer tasks, meanwhile still monitoring the patient for safety. The team can test the effectiveness of these interventions with the use of aim measures including outcome measures, process measures and balancing measures. These allow for feedback on if the changes and interventions initiated are effective and an improvement (Robert, Murray, & Provost, 2009). The team could also consider using a PDSA cycle for the analysis for effectiveness. This method uses four continuous steps, Plan the intervention, Do or implement the change, Study the outcome of the intervention for improvement or changes, then Act or decide if further changes need to be made for the improvement process to be effective (Robert, Murray, & Provost, 2009). A different method of quality improvement could be used to analyze the given sentinel event, known as Failure Modes and Effects Analysis or FMEA. This is systematic method for evaluating processes to identify where and how it might fail, and acts proactively to make changes to improve quality and safety. Similar to a root cause analysis, the FMEA process should start
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