Describe The RCA Process

The main objective of Beaumont Hospital is to provide high quality, efficient, accessible services, in a caring environment for Southeastern Michigan residents. Beaumont Hospital believes that patient safety is just as important as medical progression. Therefore, Beaumont Hospital’s risk management program consists of identifying hazard associated risks, controlling risks, and monitoring the effectiveness of procedures/practices. Risk is a part of patient care and services because everything doesn’t always go according to plan. Catastrophic patient injuries often occur because of unanticipated failures. The risk management team is responsible of effective surveillance, analysis, and prevention of events which may injure patients, lead to malpractice claims, or cause loss to the health care system. The risk management staff at Beaumont use the Failure Mode and Effects Analysis (FMEA) as a tool to anticipate what might go wrong with a process or product and how that failure effects the patient. FMEA is designed to dissect a particular process into its individual steps, isolate the potential steps that could cause the problem, assign a specific risk level to each abnormal step, analyze the risk potential for the process, and assign and action plan to correct the problem (Fibuch & Ahmed, 2014). The risk management team also evaluates and modifies potential problems. Beaumont Hospital’s risk management team helps avoid or eliminate risks by identifying an alternate

Sentinel events are a major cause of deaths in hospitals, these deaths may have been prevented if there was not a break down in the communications process. Due to the rise of such events it has been decided that by the Commission that National Patient Goals would include patient safety as an area of focus.

One of the most critical factors which contribute to the number of preventable cases of healthcare harm is the culture of silence surrounding these cases. The fear of medical providers to report incidences is related to the possibility of punishment and liability due to a medical error (Discovery, 2010). The criminalization of some acts of medical error has resulted in job dismissal, criminal charges and jail time for some healthcare workers. This is despite the fact that the system they are working in helped to create the situation which led to the error in the first place. Human error, due to fatigue and system errors can result in deadly consequences, but by criminalizing the error it effectively shuts down the ability to correct the root problem. Healthcare workers, working at all levels within the medical system, can provide valuable input on how to improve the processes and prevent harm from occurring (Discovery, 2010).

The process is an action plan that tends to illuminate on the strategies to be employed with the purpose of reducing the risk of a similar sentinel event such as that of Mr. B’s scenario. It addresses the responsibility for the oversight, implementation, pilot testing, as well as timelines and strategies for the measurement of actions that are effective (Lewis et al, 2014). All the root cause analysis (RCA) findings conducted above should help in the determination of the appropriate action plan. The appropriate improvement plan in this scenario should encompass the reevaluation of the events that led up to the code blue of Mr. B. The plan should look at the staffing mix, if the licensed personnel are trained appropriately, the patient to nurse ratio in the ER and the types of patients that were in the ER at the time. When

There are two common ways to handle a medical error. One is by blaming the individual or things when the error occurs, called it the “culture of blame”. The other one is by focusing on the safety goal using effective systems and teamwork, called “culture of safety". We may say that one is more applicable than the other, or maybe one is more beneficial than the other. In real life though, only one can be applied in a healthcare system, the one that is proven effective regardless its origin, pragmatic, or .

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

Patient safety is of major concern in healthcare settings due to the preventable nature of events that sometimes lead to serious injury, and even death, for patients. This was catapulted to the forefront of healthcare delivery in 1999 when the Institute of Medicine wrote a scathing report; To Err is Human: Building a Safer Health System, that highlighted "the lack of safety for patients in healthcare organizations" (Ulrich and Kear 2014). The National Patient Safety

A root cause analysis (RCA) is a “systematic approach to understanding the causes of an adverse event and identifying system flaws that can be corrected to prevent the error from happening again” (Huber & Ogrinc, 2010). The root cause analysis is used to determine why the problem occurred in the first place and to identify the cause of a problem using a specific set of steps (Mind Tools, n.d.). The RCA team which consists of interprofessionals who are knowledgeable of the issues and processes related to the incident and the people who are involved in the incident should be formed first before the RCA meeting takes place (Huber & Ogrinc, 2010). In the given scenario, the team includes the emergency department (ED)

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

The AFSPP also provides leaders and VA personnel with an Investigative Interview Policy. This policy states, “Following any investigative interview when suicidality is suspected, the investigator is required to 'hand-off ' the individual directly to the commander, first

In order to improve something, it must first be measured. Therefore, it is the safety policy of the Department of Veterans Affairs that incidents involving the safety of patients or staff members are reported and that the results of this reporting be trended nationwide to identify problem areas and opportunities for improvement.

Sentinel events occur, but finding out the root cause of what may happened is used to improve patient safety. According to the National Patient Safety Foundation (2015), “RCA is a process widely used by health professionals to learn how and why errors occurred,” and “investigating the event in question with the intent of eliminating the possibility or reducing the likelihood of a future similar event.” The most crucial step in the root cause analysis and action process is to identify actions to eliminate or control vulnerabilities and hazards from the cause of death (RCA2 Improving Root Cause Analyses and Actions to Prevent Harm, 2016).

A significant quality improvement issue that has been implemented triggering one to reevaluate how their tasks are performed and care is given is a sentinel event. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) describes numerous patient safety measures with a sentinel event being one. The purpose of a sentinel event is to recognize an event, reduce further risk, prevent future injury or harm, learn from the experience, and prevent it from happening again. A sentinel even is defined as an unforeseen incidence that may include serious physical, psychological injury or death and can include loss of limb or function (www.jointcommision.org). Implementing sentinel events by educating staff on what a sentinel event

Safety First is a phrase most have heard throughout their career, but what impact does that have when there is an increase of safety incidents on base? Newly appointed safety officers inherit any outstanding safety challenges as well as any benchmark programs that brings safety to light. However, if the program is broken the safety officer must utilize the skills harbored within assigned personnel to make a difference for the betterment of the wing. As the new wing safety officer, I have been tasked to eradicate the trends in safety mishaps and make sure there is a process in place to prevent future occurrences. This paper will outline an

The Cardiac Catheterization Lab is a highly specialized area of work, and therefore does require some specialized training for its nurses. Among the requirements include a background in intensive care nursing and having Advanced Cardiac Life Support certification. Some nurses were also Cardiovascular Nurse-Board Certified, and had X-ray training and licensure. Because it can be a very high intensity area, the VA does not accept new graduates to the Cath Lab. With its intensity, I inquired of several nurses what techniques they utilize to cope with traumatic events. Sara discussed how much she relies on her fellow coworkers in emergent events to step up and be willing to jump in and assist as needed. She also mentioned how each nurse attends a biweekly meeting with several other staff members to discuss any major successes or errors which have occurred. Sara explained this time as an excellent learning opportunity, as well as an outlet when each person on the team can share their thoughts.