Organizational Systems and Quality Leadership
A. Root cause analysis, RCA is used to determine the cause of events, sentinel events and near misses in healthcare and how to react to prevent re-occurrence of the issue. Many hospitals, offices and other healthcare facilities around the world use this method.
A1. 1. Identify what happened?
The team must describe the event to organize information about the event. Some teams create a flowchart of the information leading up to the event. It allows an organized picture of what happened in order leading to the event. (Patient Safety 104: Root Cause and Systems Analysis.)
2. Determine what should have happened?
The team has to identify what should have happened in an ideal event. Some teams find it useful to complete a flowchart of how things should have been done and compare it to the flow chart created in step 1. (Patient Safety 104: Root Cause and Systems Analysis.)
3. Determine the cause
This is where the team determines the contributing factors to this event. They look at direct causes of the event which are the more obvious issues. Then they look at contributing factors that are indirect in nature. It is also useful for the team to ask "why" five times to get down to the root cause of the incident. Some teams also find it useful to use the fishbone diagram to investigate and connect possible causes of certain events. (Patient Safety 104: Root Cause and Systems Analysis.)
4. Develop a casual statement
A causal statement correlates the cause to its effects and then back to the main event that prompted the root cause analysis in the first place. A casual statement explains how facts/factors about current conditions contribute to bad outcomes for patients and staff. A casual statement has three parts; the cause, the effect, and the event. (Patient Safety 104: Root Cause and Systems Analysis.)
5. Generate a list of recommended actions to prevent reoccurrence
Recommended actions refer to changes which the Root cause analysis team hopes will assist in preventing the event under review from recurring. (Patient Safety 104: Root Cause and Systems Analysis.) Recommendations may fall under the following groups;
Improving or updating the software
Employing forcing functions which physically hinder users from making recurrent errors
Ensuring redundancy, for instance using backup systems or double checks
Establishing new policies
Simplifying the process
Training the staff
Applying cognitive aids, for example, mnemonic devices
6. Prepare a summary and share it.
This is a chance to engage with other members of the group to create the next steps in the process. Some groups use flowcharts for this as well to keep information in an organized fashion.
A2. From this scenario, Mr. B passed away 7 days after his event occurred. Mr. B passed away from complications of sedation that led to cardiopulmonary arrest. One of the main causative fact...