Mhm/522 Root Cause Analysis
Trident University
Erica L. Montgomery
Module 3 Case Legal Incident Reporting Requirements
MHM/522 Legal Aspects of Health Administration
Dr. Paulchris Okpala
May 18, 2015
Root Cause Analysis and why it was used
Root Cause Analysis (RCAs) is investigations to severe adverse events carry out by experts. This is to determine what the problem is. Many members of an institution for patient safety and quality improvement programs normally lead the RCA. Experts are responsible for making sure that the process main focus is on the systems, relatively than an individual, action. For this case other members should include an ICU physician, and the emergency department where vasopressors medication are often administered.
Based on the …show more content…
As an organization they are responsible for the safety of patients. Fortunately, most errors are caught, and those that are missed usually do not lead to adverse outcomes. However, this may not apply to certain high-risk medications (e.g., intravenous potassium chloride or insulin) justifying a more aggressive approach toward preventing errors in their use. We believe that vasopressin should be considered a high-risk medication, since it has a narrow therapeutic window and is known to cause the serious adverse cardiovascular effects seen in this patient when recommended doses are exceeded (Bagian, Gosbee, Lee, Williams, McKnight, Mannos, …show more content…
Potential solutions should be identified for as many causes on the map as possible. Once the potential solutions have been identified, the next step is to identify the solutions that will best reduce the risk for the organization involved. These solutions become action items. Following are some action items that have been put into place by various organizations in order to reduce the risk of medication errors (IMNAP, 2000).
References:
Bagian JP, Gosbee J, Lee CZ, Williams L, McKnight SD, Mannos DM.
The Veterans Affairs Root Cause Analysis System in action. Jt Comm J Qual Improv. 2002; 28:531-545.
Gerberding JL. (2002) Hospital-onset infections: a patient safety issue. Ann Intern Med.
137:665-670.
Hofer TP, Kerr EA, Hayward RA. (2000)What is an error? Eff Clin Pract.
; 3:261-269.
Institute of Medicine National Academy Press ' To Err is Human: Building a Safer Health System (2000),
Mengis, J., & Nicolini, D. (2010). Root cause analysis in clinical adverse effects.
Nursing Management,
Erica L. Montgomery
Module 3 Case Legal Incident Reporting Requirements
MHM/522 Legal Aspects of Health Administration
Dr. Paulchris Okpala
May 18, 2015
Root Cause Analysis and why it was used
Root Cause Analysis (RCAs) is investigations to severe adverse events carry out by experts. This is to determine what the problem is. Many members of an institution for patient safety and quality improvement programs normally lead the RCA. Experts are responsible for making sure that the process main focus is on the systems, relatively than an individual, action. For this case other members should include an ICU physician, and the emergency department where vasopressors medication are often administered.
Based on the …show more content…
As an organization they are responsible for the safety of patients. Fortunately, most errors are caught, and those that are missed usually do not lead to adverse outcomes. However, this may not apply to certain high-risk medications (e.g., intravenous potassium chloride or insulin) justifying a more aggressive approach toward preventing errors in their use. We believe that vasopressin should be considered a high-risk medication, since it has a narrow therapeutic window and is known to cause the serious adverse cardiovascular effects seen in this patient when recommended doses are exceeded (Bagian, Gosbee, Lee, Williams, McKnight, Mannos, …show more content…
Potential solutions should be identified for as many causes on the map as possible. Once the potential solutions have been identified, the next step is to identify the solutions that will best reduce the risk for the organization involved. These solutions become action items. Following are some action items that have been put into place by various organizations in order to reduce the risk of medication errors (IMNAP, 2000).
References:
Bagian JP, Gosbee J, Lee CZ, Williams L, McKnight SD, Mannos DM.
The Veterans Affairs Root Cause Analysis System in action. Jt Comm J Qual Improv. 2002; 28:531-545.
Gerberding JL. (2002) Hospital-onset infections: a patient safety issue. Ann Intern Med.
137:665-670.
Hofer TP, Kerr EA, Hayward RA. (2000)What is an error? Eff Clin Pract.
; 3:261-269.
Institute of Medicine National Academy Press ' To Err is Human: Building a Safer Health System (2000),
Mengis, J., & Nicolini, D. (2010). Root cause analysis in clinical adverse effects.
Nursing Management,