Examples Of Root Cause Analysis

Root Cause Analysis (RCA) is a popular and often-used technique that helps people answer the question of why a problem occurred in the first place. Healthcare, in my opinion, is an area where this approach is very important and crucial to implement since it helps determine what and why something happened as well as figuring out what to do to reduce the likelihood of it reoccurring. I personally never knew anything about RCA but now that I do it is a very crucial practice to implement since it can show results. RCA assumes all systems are interrelated so by tracking back actions you can discover where the problem started and how it grew into the symptoms you are now facing. None the less this is a very important tool since it is able to find the hidden flaws in the system and

Root cause analysis process will utilize a systematic step-by-step approach to help identify all causative factors leading to this sentinel event. The main purpose of the Root Cause Analysis is to understand how the event happened, why did it happen, and what can be done to prevent an event from happening again. The first step, collect all necessary data associated with this event such as: current policy and procedures, incident report, Mr. B’s health history, environmental flowcharts, dispensed medications, equipment and staffing factors relevant to the event. The process of identifying causative factors can begin once all the data is collected. The goal, of a Root Cause Analysis, is to identify interventions to prevent an event from reoccurring.

A root cause analysis is a systematic approach utilized to identify problems within an event and create a plan for preventing that problem from recurring in the future. To be effective, a timeline of the events are created to help identify those areas that may be the reason for the problem or event, and the relationship between the causal factors and those factors identified to be a reason for the event to have occurred.

In order for any problem to be solve first a person or persons have to know the root of the cause. According to

The Fourth Amendment of the United States Constitution states the following: the right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no warrants shall issue, but upon probable cause, supported by oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized (Cornell University Law School, 2015). Citizens regularly exercise their Fourth Amendment right when coming into contact with a law enforcement officer.

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).

: In a similar research on cancer patients, Cohen, Ellis, Ownby, Rude, & Bailey (2003) performed a retrospective study to determine whether application of JCAHO standards has been followed while caring for the patients with pain or not. The study was performed in 5 hospital in a large city in Southwest, USA. A total of 150 patients were selected both from inpatient and outpatient department. All patients were from diverse population with a mean age of 57 years. The sample consisted total of 117 charts, 80 from inpatient and 37 from out patients. Data was collected between August and November 2000. Review of charts were done to check for followed documentation criteria for assessment, management and reassessment of pain in patients with cancer. This

with significant results possibly being a side effect of large sample sizes. Further there were

To be arrested means to be taken into custody by a legal authority. When a person is arrested there are certain rules and regulations that a police officer must follow and/or enforce. There are only two ways to get arrested: probable cause and an arrest warrant. Probable cause is a reasonable belief that someone has commited a crime by an officer. Probable cause has to be based on facts, a person can't just get arrested just because an officer has a hinch. An example of probable cause is if let's say an officer responds to an alarm at a store and the person is hiding in the back of the store and has blood running down his arm, the officer then would have a probable cause to arrest person. If you are ever stopped by the police you may be frisked

Healthcare facilities accredited by Joint Commission have an obligation to conduct a root cause analysis (RCA) after a sentinel event Root cause analysis (RCA) is a process that is used to identify origin of a problem in a system in order to develop corrective action plan. In healthcare sector, root cause analysis, therefore, is conducted to determine the factors that contributed to a sentinel event.

What factors did the Root Cause analysis reveal that contributed to the system failure problem?

McDonagh (2013) stated that pressure ulcer is a one of the indicator to represent of quality of patient care. University Hospitals Coventry and Warwickshire Trust in England carried out a special campaign to prevent and to remove avoidable pressure ulcer with use of several strategies such as “Root cause analysis and performance review, equipment gap analysis, “documentation review, review of staff education, 100 Days free campaign, and use of social media” (McDonagh, 2013). McDonagh (2013) mentioned that “Root cause analysis and performance review” is an analyzing tool for patient safety incidents thus it helps to prevent safety incidents. During this special campaign, nursing staff’s education was empathized and Tissue Viability Team developed

• Many challenges stem from not understanding how to navigate many of the health systems. (Seniors may not be able to navigate the complicated healthcare systems).

A root cause analysis is a systemic approach to identify problems within an event in an effort to help prevent them from recurring in the future to another patient. To be effective this analysis should include a timeline. This timeline is created to promote the identification of those areas that may be the cause of the problem or event. This timeline should also explore the relationship between the causal factors and those factors identified to be the cause for the event to have ever occurred. According to The Joint Commission (TJC), a root cause analysis should focus “primarily on systems and processes, not on individual performance” (The Joint Commission, 2013).

To get the root cause of a problem is to investigate thoroughly or to dig the problem deeply to find out the utmost causation of the problem so that it can be resolved accordingly. It is crucial to figure out the root cause of problem, whether it is a part/ a function/ a party or whatever that could not fulfill its responsibility and why that happens in first place. The right way to do is to trace back to every single layer of the problem, constantly wonder “Why?” to filter the surface to discover the hidden root cause of problem.