ROOT CAUSE ANALYSIS

ROOT CAUSE ANALYSIS

Review the case scenario included in this week’s media resources, and examine the process flow chart, cause/effect diagram, and Pareto chart related to the case scenario.

In the scenario, the nurse manager and the director of pharmacy blame each other for the error. The facilitator (quality assurance person) asks everyone to avoid blaming and focus on applying the tools to analyze the data and get to the root cause of the error. While all of these tools contribute, for this Discussion, select one tool to analyze.

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

BY DAY 3

Post each of the following:

• Analyze the composition of the RCA team. Explain what knowledge they can contribute to the RCA.
• Describe the collaboration in the case study that led to effective problem solving. Identify the evidence you observe in the scenario that demonstrates effective collaboration and the avoidance of blaming.
• Explain the team’s process in testing for and eliminating root causes that were not contributing.
• Select one of the performance improvement charts presented in the scenario and critique its effectiveness by explaining how it contributes to identifying the root cause and determining a solution to prevent repeat medication errors.
• Identify the contributing factors and discuss how to prevent this kind of error from occurring in the future.

Support your response with references from the professional nursing literature. Your posts need to be written at the capstone level.

Notes Initial Post: This should be a 3-paragraph (at least 350 words) response. Be sure to use evidence Links to an external site.from the readings and include in-text citations Links to an external site.. Utilize essay-level Links to an external site.writing practice and skills, including the use of transitional material Links to an external site.and organizational frames Links to an external site.. Avoid quotes; paraphrase Links to an external site.to incorporate evidence into your own writing. A reference list Links to an external site.is

required to read

• Spath, P. (2018). Introduction to healthcare quality management (3rd ed.). Health Administration Press.
  • Chapter 4, “Evaluating Performance” (pp. 79-118)
  • Chapter 5, “Continuous Improvement” (pp. 119-142)
  • Chapter 6, “Performance Improvement Tools” (pp. 143-174)

    Note:Although these chapters are previously assigned readings, please review them in preparation for this week’s material.

• Yoder-Wise, P. S. (2019). Leading and managing in nursing (7th ed.). Mosby.
  • Chapter 18, “Leading Change” (pp. 319-335)

• Document:Fish Bone: Cause-Effect Diagram (PDF)Download Fish Bone: Cause-Effect Diagram (PDF)

• Document:Pareto Chart: Medication Error Analysis (PDF)Download Pareto Chart: Medication Error Analysis (PDF)

• Document:Process Flow Chart: Medication Administration (PDF)

• Walden University, LLC. (2016). Root cause analysis at Downtown MedicalLinks to an external site. [Interactive file]. Walden University Canvas. https://waldenu.instructure.com

• Walden University, LLC. (2016). RCA dramatization 1[Video]. Walden University Canvas. https://waldenu.instructure.com

  Note: The approximate length of this media piece is 4 minutes.

  Case scenario involving medication error including pharmacy, physician, and nurse—interdepartmental collaboration.
  Interactive media—students select options that generate chart based on choices

  (Voiceover reads the document aloud—include a downloadable pdf).

Solution:

The composition of the RCA team in the case scenario appears to include a nurse manager, director of pharmacy, and quality assurance facilitator. The nurse manager brings knowledge and experience in patient care and the nursing process, while the director of pharmacy brings knowledge and experience in medication management and pharmacology. The quality assurance facilitator brings knowledge and experience in quality improvement and problem-solving processes. All three members of the team bring valuable knowledge and expertise that can contribute to the RCA process.

The collaboration in the case study appears to involv………..