Root cause

QUALITY AND SAFETY: REFLECTION. QUALITY AND SAFETY: DEVELOPMENT OF PROFESSIONAL DEFINITION. The WGU nursing program helped me in developing my professional definition of quality and safety by enlightening my understanding of root cause analysis, and system failures. The IHI course was an eye opener in my understanding of quality improvement, and the processes required to enhance safety and quality improvement. The courses that really assisted me in my definition include, the Organizational Systems

My teammates and I have been working on completing an upgrade of our software system since February of this year. The system in question is vital to our business, so we have planned accordingly to ensure that the process will be tested thoroughly and delivered as fast as possible. For the last five months we have operated without a target release date. The process has been difficult and we have encountered numerous issues along the way that have elongated the project. A couple of weeks ago, our team

2 Organizational Systems This paper is the analysis of the avoidable sentinel event of Mr. B, a sixty-seven year old patient who was admitted to the emergency room with left leg and hip pain following a fall. A root cause analysis will help identify key elements which led to the unfortunate event. A plan of action to develop a change theory will help formulate an improvement plan to prevent future occurences like that of Mr. B. A failure

It is said that it would make sense to look at root causes of problems rather than immediate causes because immediate causes are the result that happens after an event without any interruption or identification. However, root causes prevents us from looking at the incorrect cause of an event. It helps us not think something is the cause because it seems so obvious. The characteristics of problems that might be better understood by looking at root causes may be actually doing tests on the problems themselves

Deutsche Allgemeinversicherung Case Summary Deutsche Allgemeinversicherung (DAV) is one of the world’s largest insurance companies. The success of the company has been contributed to its product offerings and “an excellent group of insurance managers” (case page 2). The company provides superior “traditional insurance management” and excellent customer service. However, the company began to face stiff competition not only from larger competitors but also from

seek help getting out of bed which puts them at a very high risk for fall. Also, in many other occasions, patients’ call lights were not even within their reach or their beds were not locked after they came back from different tests. Patients’ fall causes many problems for health care system including patient injury, higher cost

for “estimating the likelihood of the top even by tracing back the causes until it has identified simple events or component states for which the likelihood can be estimated2. In the process you continue to look for underlying causes until you have a clear idea of the failure and what may be done to manage or mitigate the failure. When developing the fault tree it is helpful to ask “why” to uncover an underlying cause. These causes are linked in the tree as “and” (where both items are necessary for

Face-to-Face communication (F2F) Businesses nowadays are constantly making an effort to monitor employee movements and improve productivity. This is where a device that can help to monitor and build profile of an employee, and improve productivity required. This will enable the organization’s management to gather business insights and improve their profitability. Prosodica will play a significant role in order to analyze performance of employees who deal with clients on a regular basis. Using

Performance Reviews. We also have in place two types of analysis which will be conducted when an unsafe condition exist. The first report is called an ACE, which means an Apparent Cause Evaluation, and the second report is called a RCA, which means a Root Cause Analysis. These process can be used to analyze the root cause of an even and recommend the necessary corrective actions that need to be taken then this information is shared within the organization to prevent future events from occurring.

performing a full database recovery. What factors did the Root Cause analysis reveal that contributed to the system failure problem? First, root cause analysis (RCA) is a problem solving method used to identify the root cause of a problem or event. The practice is believed to work best when attempting to address, correct, or eliminate root causes as opposed to simple addressing the immediate symptoms. By identifying the root cause of a problem, it can create effective corrective actions that