Root Cause Analysis
Case study: A new RN is in the process of orientation to the unit. One of her patients asked for pain medication. She mistook hydromorphone for morphine sulfate and administered 2mg of morphine sulfate instead of Dilaudid. The patient was allergic to morphine sulfate and suffered a mild allergic reaction consisting of a rash and itching.
1. What are the purposes of doing a RCA for an event such as this?
Answer:
The purposes of Root Cause Analysis (RCS) is to find out what happened, why such error did happen, and how to prevent it from happening again .The RCA process aimed to identify the root cause of the problem. It is a tool for identifying prevention strategies.
Its effort is to build a culture of safety and move beyond the culture …show more content…
of blame ("Root
Cause Analysis - VA National Center for Patient Safety," n.d.). The RCA will serve as a tool in looking in-depth the facility’s system, rather than scrutinizing the individual who made the error (like this new RN).
2. Who should be involved in a root cause analysis of this event? Why?
Answer:
RCA is a multi-disciplinary process that involves experts from the frontline services. This includes the participation by the leadership of the organization and those most closely involved in the process and systems. This means that the involvement of the new RN is necessary in this case. The new RN should be involved because she has the most familiarity with the situation. The team should provide a supportive environment of the new nurse, moving from a mind-set of an individual blame to a mind-driven in identification of systematic error (In Patole, 2015, p. 105).
3. Is the new RN to be punished or is the system to be investigated to determine how it allowed this error to happen?
Answer:
The new RN should not be punished and the system needs to be examined in order to prevent the reoccurrence of the error.
The in-depth analysis of the situation and possible causes probably identifies changes that need to be made to systems which may result in changes in practice (In Patole, 2015, p. 105). The main goal in executing of an
RCA is to strengthen a culture of safety therefore RCA is based on prevention, not punishment. It focuses on the “how” and the “why”? , and not on the ‘who’ ("Root
Cause Analysis - VA National Center for Patient Safety," n.d.).
4. What are the steps involved in the RCA process?
Answer:
The steps in the RCA process involved: the formation of key stakeholders, investigation of the situation and collection of data, identification of possible causes, development and presentation of recommendations, and the implementation of “tests of change” for the new process (In Patole, 2015, p. 105). Probably an RCA action plan framework template can be a valuable tool in the process.
5. What should be the results of an RCA?
Answer:
A well-conducted RCA can provide significant value addition to various quantitative measures of quality of care. A no hindsight bias or bias RCA can reduce the frequency of occurrence of the error or sentinel event in question (In Patole, 2015, p.
105).
1. What are the purposes of doing a RCA for an event such as this?
Answer:
The purposes of Root Cause Analysis (RCS) is to find out what happened, why such error did happen, and how to prevent it from happening again .The RCA process aimed to identify the root cause of the problem. It is a tool for identifying prevention strategies.
Its effort is to build a culture of safety and move beyond the culture …show more content…
of blame ("Root
Cause Analysis - VA National Center for Patient Safety," n.d.). The RCA will serve as a tool in looking in-depth the facility’s system, rather than scrutinizing the individual who made the error (like this new RN).
2. Who should be involved in a root cause analysis of this event? Why?
Answer:
RCA is a multi-disciplinary process that involves experts from the frontline services. This includes the participation by the leadership of the organization and those most closely involved in the process and systems. This means that the involvement of the new RN is necessary in this case. The new RN should be involved because she has the most familiarity with the situation. The team should provide a supportive environment of the new nurse, moving from a mind-set of an individual blame to a mind-driven in identification of systematic error (In Patole, 2015, p. 105).
3. Is the new RN to be punished or is the system to be investigated to determine how it allowed this error to happen?
Answer:
The new RN should not be punished and the system needs to be examined in order to prevent the reoccurrence of the error.
The in-depth analysis of the situation and possible causes probably identifies changes that need to be made to systems which may result in changes in practice (In Patole, 2015, p. 105). The main goal in executing of an
RCA is to strengthen a culture of safety therefore RCA is based on prevention, not punishment. It focuses on the “how” and the “why”? , and not on the ‘who’ ("Root
Cause Analysis - VA National Center for Patient Safety," n.d.).
4. What are the steps involved in the RCA process?
Answer:
The steps in the RCA process involved: the formation of key stakeholders, investigation of the situation and collection of data, identification of possible causes, development and presentation of recommendations, and the implementation of “tests of change” for the new process (In Patole, 2015, p. 105). Probably an RCA action plan framework template can be a valuable tool in the process.
5. What should be the results of an RCA?
Answer:
A well-conducted RCA can provide significant value addition to various quantitative measures of quality of care. A no hindsight bias or bias RCA can reduce the frequency of occurrence of the error or sentinel event in question (In Patole, 2015, p.
105).