Root Cause Analysis Paper

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

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.

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

A root cause analysis (RCA) looks at an event and considers what happened, why it happened what will be done to prevent it from happening again and how will we know that the changes made will improve the safety of the system. It takes into consideration causative factors, errors and hazards that led to a sentinel event. In this case it was a patient’s death. RCA should not look to place blame on people, but rather processes that need to be improved.

It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).

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.

Never events are serious medical errors that are often preventable. When such events transpire, it is necessary to fully assess the situation so that these errors can be prevented in the future. Root cause analysis (RCA) is a tool employed by healthcare facilities to analyze adverse events and the systems that lead to them.

Root cause analysis (RCA) is used in different fields to conduct a systematic search to find the causes of a specific sentinel event (Jacob, 2010).  The main goal for conducting a RCA is to prevent similar adverse events from happening in the future (Jacob, 2010).  In this paper, I will use the scenario provided in the task to create a complete RCA report as well as improvement plans that will prevent similar incidents from happening again.

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

A root cause analysis is defined as, “a process for identifying the basic or causal factors that underlies variation in performance, including the occurrence or possible occurrence of a sentinel event” (Cherry & Jacob, 2011, p. 442). Involved participants, in the case, the emergency room physician, registered nurse, and licensed practical nurse present during the sentinel event, as well as the emergency room nurse manager, and Chief Nursing Officer, should meet to discuss the events leading up to the patient’s (Mr. B’s) death and establish a root cause analysis. They should explore all hazards and errors in Mr. B’s care. Data should be gathered, facts surrounding the death analyzed, and causative factors should be explored to establish

A root cause analysis (RCA) is a method by which we can examine a serious adverse event and identify the cause, or causes, that led up to the event. Although personnel are involved in these events, the primary purpose of the RCA is to identify the cause, not to assign blame (Agency for Healthcare Research and Quality, 2014). It is through identifying a cause, or causes, of an adverse event that we can improve on patient care processes and thereby patient safety. The RCA is designed as a specific protocol that starts with data collection looking at the sequence of events that led to the

A root cause analysis (RCA) is an essential tool that can be used to examine and understand the ways in which systems fail as well as discuss those specific failures that led to a specific adverse event and potentially implement steps or behaviors to prevent that event from happening in the future (Ogrinc & Huber, 2013). In the case study presented, a number of system failures may have contributed to the patient outcome. As such, an RCA of the case study would help determine those specific

to find solutions to the errors that were found so that a reoccurrence of the same error doesn’t

The root cause analysis, RCA is used in the health care profession to find flaws and opportunities for improvement in the nursing environment. It is a structured analysis method for serious adverse health care events. Moreover, by conducting a RCA, health care practitioners determine the underlying problems that intensify the likelihood of errors with avoidance of focus on individuals’ mistakes. A systems approach is used to detect and eliminate active and latent errors to prevent future harm. As a result, RCAs follow a pre-specified protocol starting with collection of data, record reviewing and participant interviews to reconstruct the event in question (Franklin, Shebl & Barber, 2012).

Honeywell utilizes state-of-the-art technology to help guarantee the flow of data and its delivery in order to prevent errors, which takes us to the second part of TotalPlant, which reduced defects monumentally: fail safing. Fail safing identifies defects, analyzes the root cause of these errors in business processes, and creates possible solutions. These root causes of errors can be tested to check for validity by asking three simple questions: “ is it a cause of the defect identified, is it possible to change the cause, and if eliminated, will the defect be eliminated or at least reduced” (Paper, Pendharkar, Rodger, n.d.)? After the root cause(s) have been identified, solutions must be generated and then one solution must be chosen based on greatest value; after a solution is chosen, a plan must be created to implement the solution. The solution must be checked for success in eliminating the defect through analysis via the action register, pareto charts, and histograms. Finally, the results have to be acted upon, meaning employees must determine steps for continuing this improvement and further improving it more by constantly repeating the fail safing process.