Root Cause Analysis

Number of Pages: 1 (Double Spaced) Number of sources: 1 Writing Style: APA Type of document: Essay Academic Level:Master Category: Healthcare Language Style: English (U.S.) Order Instructions: Root Cause Analysis, Part 1 Root cause analysis (RCA) is a standard tool used to help health care organizations learn from errors, particularly those that result in harm. RCA is applied to address three key questions about a particular situation. •What happened? •Why did it happen? •What can be done to prevent it from happening again? For this Discussion, you and your colleagues will work together as a team throughout Weeks 4 and 5 to analyze a particular situation. You must use the Discussion forum, but it is up to your team to determine how you will collaborate. Depending on how you structure the process, it may be necessary for each person to make multiple postings. In addition to incorporating information from various Required Resources, you are encouraged to conduct your own research for this Discussion using the Walden library and credible Web sites. Each team member will be evaluated individually according to the Discussion rubric in the Course Info area. In addition, you will have the option to submit a Team Evaluation form at the end of Week 5. It is highly recommended that you select a team facilitator (preferrably by Day 2 of Week 4) to lead the dialogue process. To prepare for and complete this Discussion: •Examine the “Appendix: Root Cause Analysis Tool,” presented on pages 182–186 of Foundations in Patient Safety for Health Professionals. This tool will serve as a foundation for the Discussion. If you were conducting a Root Cause Analysis in a health care organization with the actual individuals involved, you would be able to use this tool more fully. For this assignment, you will use this tool as a jumping off point for discussion and analysis. •As a team, select a specific type of sentinel event/scenario to focus on for this Discussion. You may choose one from the Joint Commission’s Web site (http://www.jointcommission.org/sentinel_event.aspx), select a case from one of the textbooks, or use an outside source. Once you have made this determination (preferrably by Day 4 of Week 4), your team facilitator should check with your Instructor to ensure that it is appropriate for this Discussion. •During the remainder of Week 4 and in Week 5, discuss each element of the Root Cause Analysis Tool in relation to your selected scenario. The following are a few questions to help guide your Discussion. ?What information from your selected scenario would help you to “fill in” each row or column of the Root Cause Analysis Tool? Identify as much information as you can for each row/column of the tool. For instance, what indicators from the scenario you have chosen should be included in response to “What are the details of the event (brief description)?” ?If certain information is not provided in your selected scenario, how would you, as a team, proceed to gather data? ?Who should participate in this analysis? Which roles or which specific individuals should be invited to participate? ?What questions or considerations (beyond what is included in the tool) would help to guide your investigation? ========================================= This is the topic . Topic: Patient Elopement resulting in Death Please include the following employees in the root-cause analysis team for this sentinel event: 1. Charge Nurse on duty at time of elopement 2. C.N.A. assigned to patient & on duty at time of elopement 3. Security Staff on duty at time of elopement 4. Physician assigned to the patient in question 5. Hospital Administrator 6. Employee Representative from Compliance/Audit or Risk Management Department 7. Social Services Representative – Potential employee in contact with family members 8. Representative from Environmental Services Department on duty at time of elopement (potentially they may have seen something) 9. Other employees as required or as identified during the investigation The Process The team will be required to gather all of the data needed to complete the puzzle of why the elopement occurred and how this can be prevented from reoccurring. The team may have to interview many employees on duty at the time of the event, watch security tapes available at the time of the event, and conduct a review of safety devices, doors, exit pathways, and procedures to get a full perspective of what occurred. Before the team can get to a solution or a complete understanding of all the events, as stated by ‘Guidance for performing root cause analysis with PIPS’, (n.d.), “the situations, contributing factors, circumstances and conditions” need to be understood and identified. This is all part of the analysis process. Please read careful and include all this information in the Root Cause Analysis, Part 1. I need my paper on time, very informative and well done!