Root cause analysis is a tool used by many businesses to determine why an event happened. This process is still rather new to the health care sector. In health care, root cause analysis can be helpful in several ways but there are limitations to its usefulness as well. The process for conducting a root cause analysis is not lengthy in terms of steps; however, it can take time to find all of the mitigating factors involved with the incident. The case study provided is a classic example of when and why a root cause analysis should be used in a health care setting. In addition, the discussion provided within the case study supports the use of root cause analysis in health care.
Root Cause Analysis and When it is Used
Root cause…show more content… First, the goals of root cause analysis include a fair and unbiased determination of the underlying reasons that the error occurred (Williams, 2008). Specifically, root cause analysis helps the organization to determine the what, when, how and why of the situation as well as how to prevent the error from reoccurring (Williams, 2008). Discovering the what, when, how and why of a specific situation and finding the proper measures to prevent the situation in the future are, therefore, the goals of root cause…show more content… These steps are as follows:
1. Define the problem (Hambleton, 2005). During this defining phase, investigators are able to determine the basics of the error - or the what, when, how and why of the issue (Hambleton, 2005). In this case, incorrect medication dosage is the what, the when is upon treatment in the emergency department and the how is simply a mistake made by medical personnel. However, the why is still unknown.
2. Develop a list of causes, whether major or minor, that could have resulted in the never event occurrence (Hambleton, 2005). During this step, the incident will be separated into causes and listed so the investigators can determine the underlying cause of the incident (Hambleton, 2005). By listing the causes, investigators can get a clearer picture of where the incident started. Did staff fail to confirm the dosage amount? Was there a breakdown of communication between emergency room staff? Did the pharmacy make an error? Was the dosage/medication checked by subsequent staff involved with the patient 's care? In other words, this discovery phase will alert investigators to the causes and their effects and determine the why or why