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Root Cause Analysis of a Case Study

  • Submitted by: dholliday59
  • on August 7, 2015
  • Category: Miscellaneous
  • Length: 2,723 words

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Root Cause Analysis of a Case Study
Alice Holliday
Western Governors University
Organizational Systems and Quality Leadership

Root Cause Analysis of a Case Study
Healthcare presents numerous opportunities for patients to be helped by healthcare personnel.   Unfortunately, there are also numerous opportunities for patients to be failed by healthcare personnel.   When patients are failed by healthcare personnel, it is required by the Joint Commission for hospitals to carry out a Root Cause Analysis in order to understand the systems within the organization that failed so that improvements can be made and the failures can be prevented from happening in the future. (Cherry & Jacob, 2011)   This paper will describe how a Root Cause Analysis (RCA) can be used following the death of a patient, and how Change Theory and Failure Mode and Effects Analysis (FMEA) can be utilized to come up with ways to prevent the failure from being repeated.
A.   Root Cause Analysis
A Root Cause Analysis is an organized process used to determine the processes that lead to sentinel events.   A sentinel event is defined by Cherry & Jacob as “an unexpected occurrence involving patient death or serious physical or psychologic injury or the risk thereof.” (Cherry & Jacob, 2011, p. 444)   The objective of a Root Cause Analysis is to identify the factors which caused the sentinel event and to identify flaws in the system which can be corrected in order to prevent a repeat of the event in the future.   A RCA is not used to blame individuals, and is not applicable when the event is intentional, or caused by negligence or a criminal act.   RCA focuses on failures in the system that can be corrected. (Huber & Ogirnc, 2014)
Before beginning the Root Cause Analysis, a multidisciplinary team is selected to review the events involved in the sentinel event.   This team is typically composed of four to six members.   These members would include representatives from Risk Management and...

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