Root Cause Analysis Paper

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.

For example, a hospital-wide policy can be made making it mandatory for all critical results to be documented and reported within the hour. Attestations can be put in place for all hospital staff to sign, holding them responsible if policies are not followed. Another suggestion would be to have all critical results reported to two sources, for example the patient’s nurse and charge nurse, to increase the likelihood of rapid documentation. The point of the corrective actions is to ensure that each staff member knows what they are responsible for. For example, laboratory staff knows to document the critical values and alert the appropriate nurse or charge nurse, the nurse or charge nurse knows to document the critical lab values or test result and to alert the ordering physician, the ordering physician knows to discuss a treatment plan with the patient and to document appropriately in the chart, etc. The point is, every staff member has a role to play in assisting the hospital in becoming one hundred percent compliant. This corrective action plan holds each staff member accountable. Those who do not comply can easily be tracked and disciplined by their supervisor.

This assignment will look at incidents and emergencies that can happen in a health and social care setting. Within my assignment I will be explaining possible priorities and responses when dealing with two incidents or emergencies in a health and social care setting. I will be discussing

The third step of root cause analysis process is identifying possible causal factors (Mind Tools, n.d.). In this step, the team would determine the factors that contributed to the event. In the given scenario, the factors that led to Mr.B’s sentinel event were his tolerance to pain medications and clinical situation (age, weight, and kidney function) were not considered. The emergency department was very busy and understaffed which caused Nurse J to leave the room and unable to monitor the patient closely. Another factor was that the

21. Report any unusual or major changes in your patient’s health, cleanliness, physical care, actions and

According to the probable cause summary created on September 28, 2015, by Officer K. P. Groome, of the Chesapeake Police Department, the following events occurred:

Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, and implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures (Business And Professions Code, n.d.).

The Declaration of the Immediate Causes Which Induce and Justify the Secession of South Carolina from the Federal Union was a legitimate decree issued on December 24, 1860, by the legislature of South Carolina, clarifying its purposes behind withdrawing from the United States.

This assignment will look at incidents and emergencies that can happen in a health and social care setting. Within my assignment I will be explaining possible priorities and responses when dealing with two incidents or emergencies in a health and social care setting. I will be discussing health, safety or security concerns that may arise from the incident or emergency. Then I will be discussing how I would respond to them.

After careful analysis of what had happened and what should have happened takes place, the RCA team should ideally focus on why the adverse events happened. In this step, the goal is pinpoint the direct causes and contributory factors (Ogrinc & Huber, 2013). By doing this, the root cause of an event can be identified. One suggestion made by the Institute of Healthcare Improvement in the root cause analysis process is to ask “Why?” five times (Ogrinc & Huber, 2013).

A threat emerges with the growing dissent northern states. Their cultures and economic systems had stark contrast at the birth of the nation. The North felt the South was addicted to the enslaving Africans to labor in their plantations. The South dislikes that President Lincoln opposes the expansion of slavery. With the tensions f their ideologies urged the country towards civil war.

Utilize logical, analytical, and problem-solving methods to audit and investigate complaints and concerns from patients, staff, and physician.

In the root cause analysis, the root cause analysis team investigates the role of multiple factors that could have contributed to the event, such as communication, equipment failures, staffing levels and/or fatigue, training, policies/procedures, and organizational culture. Following the analysis, the facility must implement a corrective action plan to implement the findings of the analysis or at least report to the appropriate state department any reasons for not taking a corrective action plan. The findings of the root cause analysis and a copy of the corrective action plan must be filed with the commissioner within 60 days of the event for the State of Minnesota. The team of clinical and quality improvement experts review the root cause analysis and corrective plan meet all criteria and that the facility is able to take steps to reduce this risk of any future adverse events. The review team will provide feedback to the facility and allow modifications to be applied until all criteria have been met. Each event can go through up to three reviews (Minnesota Department of Health,

Incident reports, less commonly known as Image Trend reports, are filled out for every call. Required within those reports are certain sections regarding pertinent medical information for proper patient care. The most well-known and hardest part of an Image Trend report is the patient

Information that is missing in this particular case in the lack of education to the medical staff