interdisciplinary team members: Risk Management‚ ED physician‚ Anesthesiologist‚ Director of Nurses‚ respiratory therapist‚ and ED Nurse Manager. The purpose of this investigation is to determine the root cause analysis (RCA) of the sentinel event‚ which occurred in the emergency room. Once the cause is identified‚ a plan of action will be established‚ and a failure mode and effects analysis (FMEA) will be done to reduce the likelihood that the new processes
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Ineffective communication is recognized as a critical safety problem in health care. In fact‚ an estimated 80 percent of serious medical errors involve miscommunication between caregivers during the transfer of patients. One example of a predictable and critical communication event is patient handoff. Patient handoff may be described as the transfer of patient information and knowledge‚ along with authority and responsibility‚ from one clinician or team of clinicians to another during transitions
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uninformed or even a little biased at times. My social life could be considered nonexistent at the moment‚ so there isn’t really anything to discuss in that area. I then realized that I have the perfect personal situation for applying the Root Cause Analysis tool to (Root Cause Analysis: Tracing a Problem to its Origins‚ n.d.). I recently returned from‚ and plan
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Organizational Systems and Quality Leadership Task 2 Western Governors University 03/15/2015 Root cause analysis (RCA) is one of the organized techniques that can be used as an analyzer in any events of adverse events. In health care settings the best method to track down an adverse event and find out the root cause of the problem‚ would increase the overall patient well-being outcome. The best approach to an adverse event would be to set up questions systematically from the point
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Root cause analysis is a collective term that describes a wide range of approaches‚ tools‚ and techniques used to uncover causes of problems (ASQ‚ n.d). Investigation starts with visible problem and or symptom followed by a series of what‚ how and why questions to identify the first level‚ higher level and finally the root cause of the problem or the system. The purpose of the inquiry is to identify the exact cause of the problem and then make a plan of action on how to eradicate or control the cause
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Root Cause Analysis (RCA) is a process that is used to identify the causes of an error or accident. In the case of Mr. B death‚ a RCA is needed to determine what may have contributed to his death. A Root Cause analysis must be complete and reported to Joint Commission in the even where injury or death occurs. Sentinel event is a major adverse even that could have been prevented (Alemi‚ 2007). The sentinel event was related to respiratory arrest secondary to conscious sedation procedure. The people
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* DMAIC produce is considered to bring very important and measurable improvements from old to new current process that are below expectation in a new business. * DMAIC brings them to achieve the new strategy along * Understand to reflect the business process : Define : Definition of the process improvement goals‚ which are consistent with customer requirements and corporate strategy. Measure : Measuring of the current process and gathering of relevant data for subsequent comparison
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Causes are sometimes easy to understand but difficult to resolve. We ask ourselves and political leaders many questions including‚ what is terrorism? What are the determinants behind their attacks? “Terrorism is an outrageous attack carried out either by individuals‚ groups or states against a human being’s religious life‚ intellect‚ property‚ and honor. It includes all forms of intimidation‚ harm‚ threatening‚ killing without just cause and everything connected with any form of armed
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Roots Causes of Family Violence When we think of family violence we think of physically hurting our family members. Not only is physical abuse an aspect of family violence but so is mental‚ emotional‚ and sex abuse. Many people still believe the misconception that family violence is a personal problem that is better dealt behind the closed doors of their homes. What they fail to realize is that family violence is a crime that not only affects the victim’s life‚ but it affects everything the victim
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Root Causes of Environmental Issues Kendele Sitter SCI/275 Environmental Science 02/28/2015 Maria West One root cause that I agree with is that we‚ as a country have become obsessed with economic growth. We have completely lost sight of our environment because of greed. Like stated in our readings this week (chapter 3)‚ people are more worried about how big their homes are or what the latest fashion is. Everywhere you look‚ be it on billboards or in the magazine you’re flipping through in
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