Root Cause Analysis For Health Care

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Introduction 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 analysis is defined as a tool used in health care quality management where both obvious and underlying causes that may lead to adverse outcomes, or potentially harmful outcomes, are sought out and analyzed to correct the faulty processes and improve outcomes (Bowie, Skinner & de Wet, 2013 & Agency for Healthcare Research and Quality, 2012). Therefore, root cause analysis is a fact-finding process in which all potential causes of the error are determined in order to understand which processes are most likely to have caused the error and aid in the development of processes and procedures so that the error is less likely to occur again. The process of conducting a root cause analysis can be performed at any point after the error is discovered (AHRQ, 2012). However, it is advisable to conduct the investigation as soon as possible to ensure that the information coming from persons involved with the care of the patient is more reliable. In addition, it is important to note that root cause analysi... ... middle of paper ... ... pharmacy order system to alert the ordering staff member when different dosages are used for differing diagnoses (Flanders & Saint, 2005) and implement procedures that treat medication doses the same as hospital procedures, i.e. checks and balances (Flanders & Saint, 2005). Conclusion Root cause analysis is a useful tool for determining all potential causes of a medical error. However, there are a number of limitations associated with this process. Quality assurance managers and investigators should be aware of these limitations to ensure a fair process in determining the cause of an error. A root cause analysis would have been very useful to the institution in the case study presented by Flanders & Saint. This medication error should not have happened and can be addressed through improvement of processes, which would be discovered during a root cause analysis.
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