Root Cause Analysis

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.

Define the Problem: Describe the type of case and what problem(s) or issue(s) should be the focus for

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

When members in the team brainstorm ideas, they will ask a lot of questions pertaining to the problem at hand and do a lot of research on it. They will also break themselves up into smaller, more workable groups to increase efficiency. In addition, the members do not just limit themselves to finding information online, but they also find out firsthand about the problem from the people who are affected by it. During their firsthand experience, they are very observant and enthusiastic in gaining knowledge from the people affected. Then, they will demonstrate, communicate and share everything that they’ve learned with the other groups. There is focused chaos during the sharing and the members are all very lively, flexible, and open. All ideas are accepted, and no idea is “bad”, no matter how crazy it is. After much sharing, the team will narrow down ideas by voting for them, and the ideas with majority of the votes will be shortlisted. When the members are tired after the brainstorming session, they will call it a day and end off on a positive note.

Another advantage of group brainstorming is that it helps everyone involved to feel that they’ve contributed to the end solution, and it reminds people that other people have creative ideas to offer. What’s more, brainstorming is fun, and it can be great for team-building!

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).

problems that are appearing and many of them can be seen to be connected to

As defined by Wood worth “problem as a situation for which we have no ready and successful response by instinct or by previous acquired habit. We must find out what to do, i.e. the solution can be found only after an investigation”.

In order to understand how to solve the problem, it is important to understand how the problem started

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.

In class, we discussed the importance of brainstorming and constantly coming up with new ideas to encourage innovation- did you use a specific process to come up with ideas?

I am uncomfortable putting work conflicts on the internet, and even more uncomfortable exposing personal relationship conflicts that should inherently be private. I also do not watch the news, because I do not trust it as a source of information. Thus, for the purposes of this essay, I shall describe the most recent inner conflict of note that I have experienced instead, and analyse it using the “Root Cause Analysis” and “5 Whys” strategies that were discussed in this week’s reading.

This report will start the analysis from the view of internal motivations and then moving to the external causes.