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).
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.
Need Writing Help?
Get feedback on grammar, clarity, concision and logic instantly.Check your paper »
- Incident Report Sentinel Events and Root Cause Analysis As a health-care professional, it is understood that the health and well being of a patient is top priority. The dedication to provide care and protection to each patient is ingrained into the very basics of nursing education. However, despite this commitment, medical errors that adversely affect the lives of patients are made everyday worldwide. These types of events are referred to as Sentinel Events. When such an event occurs, there is a need for an immediate investigation and response.... [tags: Hospital, Patient, Hospital accreditation]
767 words (2.2 pages)
- In a time of economic hardship, Americans have become more and more conscious of how they spend their money. For obvious reasons, nearly all consumers would agree that overpaying for a product is bad, what they don’t realize is that over half of Americans already do. The american health care system has a multitude of flaws with a bunch of causes that raises cost, but at the root of it all is what sets america’s system apart, private insurance. Because of private health insurance,the cost of health care in the United States has risen exponentially.... [tags: Health care, Health economics, Healthcare]
1459 words (4.2 pages)
- 1. Behaviors to Improve Patient Safety. There are five behaviors in which I, as a health care professional, can practice in order to improve safety for patients in my direct care. These include following written safety protocols, speak up when you have concerns, communicate clearly, don’t let yourself get careless, and take care of yourself. By adhering to simple, basic protocols such as hand washing you can be a key player in reducing the spread of infection to your patients and thus, keeping your patients safe.... [tags: Health care, Health care provider, Patient]
1072 words (3.1 pages)
- The eagerness to promote an environment of safety for the patients, their families, and the health care providers as well as promoting compliance, led me to dig deep into the issue. This also promotes advocacy, being a voice for those patients who are unable to express their concerns and their rights due to disability or medical condition. Determining the barriers and needs that prevent the inappropriate use of physical restraint by a series of data collection through observation, chart audit, and informal questionnaires was compiled.... [tags: Patient, Health care, Health care provider]
1089 words (3.1 pages)
- Quality Measurement Research Paper Health care leaders in the United States strive for excellence in all areas within their organization. Hospital executives invest time and capital purchasing performance improvement tools that are capable of assuring organizational quality standards are met. The following paragraphs will summarize, evaluate and example how the following methods of quality measurement can improve organizational effectiveness: Six Sigma and Lean Methodologies. Six Sigma Six Sigma is a powerful process improvement tool originally developed as a business strategy and eventually the benefits of Sig Sigma were acknowledge by the health care industry.... [tags: hospital executives, six sigma]
1506 words (4.3 pages)
- Can moral obligations be blinded by religious views. For some, the sense of religious pride reigns stronger than the moral belief. In the beginning, citizens of Hillsboro from the novel Inherit The Wind by Jerome Lawrence and Robert E. Lee, acknowledged religion as something far more valuable than the moral truth. As the novel continues the prosecuting attorney, Matthew Harrison Brady, enters the scene which reveals the prejudice of the courtroom regarding the case of Bertram Cates. When Brady takes on the challenge, the exposure of excessive pride and boasting of recent cases won can be seen as a certain Dramatic Personality Disorder from a medical standpoint.... [tags: Literary Analysis ]
1538 words (4.4 pages)
- Introduction: This case is about Corona Data Analysis (CDA) which processes claims for health insurance. CDA has about 90 employees out of which 75% work in the operations side of the business which is also the side of the business we were hired to consult upon. We were hired by the quality manager, Gordon Yu, who was hired by the CEO, Julieanna Sugumar. Gordon Yu has asked us to analyze the defects per unit, DPU, defects per million units , DPMO, and K-sigma quality levels. He has given us important access to the processing data and the number of errors that were made in 5 different categories including name, ss#, address, claim code, and claim date fields.... [tags: claims, health, insurance, money, business]
822 words (2.3 pages)
- I decided to use the root cause analysis method in order to think and try to resolve my problem. The first and second step is to define what my problem is. Recently, I have been battling feelings of depression. At first, I dismissed the feelings as something temporary. When the feelings persisted for a couple of months, I decided to address the issue. I did not want to go to the doctor because it felt like that would not help me. I did not want to take antidepressants or pay for someone else to fix my problem.... [tags: Emotion, Feeling, Feelings, Want]
1017 words (2.9 pages)
- Discuss and Contrast the Maori and Social models of Health "Health is a social, economic and political issue and above all a fundamental human right. Inequality, poverty, exploitation, violence and injustice are at the root of ill-health" (Braum, 2008, p.3).The Maori model of Health, in particular "Whare Tapa Wha" is based on four simple key aspects to ensure overall general health and well being, Taha Wairua, Taha Hinengaro, Taha Tinana and Taha Whanau. These are the basic foundations or stepping stones to an significant determinant of good health, that can be found across the many multiple health models (Durie, 1998, p.66).... [tags: anthropology, world medicine]
984 words (2.8 pages)
- A root cause analysis is a systematic approach utilized to identify problems within an event and create a plan for preventing that problem from recurring in the future. To be effective, a timeline of the events are created to help identify those areas that may be the reason for the problem or event, and the relationship between the causal factors and those factors identified to be a reason for the event to have occurred. In the case of Mr. B’s, an investigation into the events surrounding to and leading up to his untimely death would be required.... [tags: Case Study, solution]
1355 words (3.9 pages)