Essay The Risk Management Program Is The Root Cause Analysis Program

Essay The Risk Management Program Is The Root Cause Analysis Program

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The risk management program used to establish a culture of safety within the organization is the Root Cause Analysis program. The facility has employed a full time patient safety manager who is responsible for conducting investigations on all adverse events at local level. The safety manager rates all the adverse incidences reported in the organization using two criteria; a) harm in terms of catastrophic to minor and b) probability in terms of frequency and remote. In this healthcare facility, harm is rated using four tier scale including a) catastrophic which includes all events that leads to permanent loss of function or death; b) major level which is associated with permanent lessening of patients body function; c) moderate level which includes lengthened stay or increased level of care and d) Minor which is associated with mild injuries. The probability of event is rated as frequent, occasional, uncommon and remote (Durham VA, 2015).
The aim or RCA program is to identify the adverse events, why it occurred and ways to prevent it from occurring again. The Durham VA has embraced a culture of safety that is not based on punishment but on prevention. The RCA team conducts an investigation on functioning of patient care systems using the Human Factors Engineering (HFE) approaches with the aim of supporting human performance. The RCA team includes representatives from frontline clinical staff as they are strategically placed to identify clinical adverse events and plausible solutions (Mills et al., 2008).
The RCA strategy is adequate because it includes analysis of human factors, environment factors, the healthcare facility processes and systems. In addition, process also involves an in-depth analysis of the cause –effect system as ...


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...ch that involves both technological and organizational influences. It is important to understand that human performance and variability is not intrinsically coupled with causes and it requires diverse components complexity is systems that do not only identify system vulnerabilities but also augment system resilience (Mills et al., 2008).
There are various systematic risk management programs that can be used effectively, but the evidence based program is the FMEA. FMEA is recommended because it is a logical risk management program that is structured in a way that it effectively evaluated processes and reveals healthcare areas that needs to be improved. One most critical advantage of this system is its ability to make early identification of single failure points or system interface that hinders success and negatively impact on patient safety (Fibuch and Ahmed, 2014).

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