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.
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 (see checklist)
Notes for Initial Post: A 3-paragraph (at least 350 words) response. Be sure to use evidence from the readings and include in-text citations. Utilize essay-level writing practice and skills, including the use of transitional material and organizational frames. Avoid quotes; paraphrase to incorporate evidence into your own writing. A reference list is required. Use the most current evidence (usually ≤ 5 years old). (Refer to AWE Checklist, Capstone)
Root Cause Analysis
Root Cause Analysis
Quality and safe care are a priority in healthcare, and to guarantee such to the patients, there is the need to continually analyze and change nursing policies and practice. Caregivers may notice a given quality of care outcome and see the need to change or improve it within the system, but to do so, they need to understand the root cause of the problem that leads to such outcome (Brook et al., 2015). Different tools can be used to complement the caregivers’ knowledge and skills in understanding the contributing factors that lead to specific outcomes in health and quality. The tools provide ideas and understanding that helps in formulating quality resolutions. Some of the tools that can be used in identifying root causes of problems include the process flow chart, cause/effect diagram, and Pareto. However, this paper will discuss the cause and effect diagram and how the quality assurance person and the root cause analysis (RCA) team apply the tool in solving a case scenario where the nurse manager and the director of a pharmacy blame each other for the error.
The firsts step before commencing any root cause analysis is to formulate An RCA team consisting of caregivers and professionals from various departments to develop an interdisciplinary team. Each team member is chosen because of their insight and knowledge in their different specializes and can help formulate evidence-based solutions, quality, and saves on healthcare costs (Swamy et al., 2018). Some of the members to include in the RCA team are the quality assurance person, the facilitator, nurse manager, director of the pharmacy, a physician, a pharmacist, a few nursing staff, a social worker, a clinical, executive sponsors, and a clinical leader. The nurses, pharmacists, and other care specialists have the mandate of providing insight on clinical matters while other leaders are there to support the decision-making process and aid in supporting and implementing the resolutions. The list does also involves people that handle prescription at a certain point. Interdisciplinary collaboration is vital to ensure holistic care is achieved.
In the scenario, the quality assurance person takes the facilitator position and asks the director of pharmacy and the nurse manager to shun the blame game of the person responsible for medical error and instead asks them to consider applying a root cause analysis tool that will quickly help identify the root cause of the error and remedy the avenues for error. The facilitator acts as a mediator who asks the two specialists to collaborate in identifying the problem. Further collaboration is noted in the RCA team’s formulation since the members work together to identify the root cause of medical errors and propose solutions. The RCA team process involves identifying the problems that probably increase the chances of mistakes. The facilitator should moderate the session to avoid focusing on individuals and the mistakes they make. The session involves brainstorming, data collection, reconstruction, and analysis of error events, to identify why the problem occurred and how it occurred. When the source of errors is identified, measures can be implemented to avert future harm and promote quality care.
The team prefers to use a cause and effect diagram, also known as a ‘fishbone’ diagram or an Ishikawa, named after Kaoru Ishikawa, the developer. The visual diagram of the tool resembles the skeleton of a fish. The cause-effect diagram is useful when brainstorming about the leading causes of medical errors that affect the quality of care and patient outcomes (Swamy et al., 2018). It produces multiple sub causes of the primary outcome. The tool’s visual display makes it easy to analyze and discuss the various reasons for the problem and decide on the corrective action. The main limitation with this tool is that it does not single out a primary root cause of the problem since every cause seems to carry equal weight. Making all the reasons look equally important creates room for bias since there may be some causes that have little impact on the end problem, but all in all, solving such causes improves the quality of care.
The cause-effect diagram aimed to assess the root cause of medical errors in the institution. Before making any recommendations, the RCA team also evaluates the proposed corrective action to ensure they are within limits of the institution’s capacity to prevent a recurrence. Proposed solutions should focus on correcting the root cause of the problem and the implementation process to properly engage the staff, minimize the problem’s frequency and subsequent consequences (Charles et al., 2016). The RCA team was thorough in assessing every medication dose prepared and the processes it passed through to understand what was done differently from the required prescription rules.
As presented in the fishbone diagram, some of the causes of medical error were errors with timing, dosage, administration route errors, extra doses, presentation errors, omissions, and prescription errors. The root cause seemed to occur due to the negligence of the involved parties. The proposed solutions to prevent the reoccurrence of the mistakes mentioned above include following the five rights of medication administration, double-check procedures, adhere to medication reconciliation procedures, safely and adequately store medication, and not hesitate to use a drug guide if unsure of anything (Charles et al., 2016). The other recommendations are to document everything and use proper handwriting in prescriptions; if uncertain, a practitioner should have the involved caregiver read it back and follow the institution’s medication administration regulations, policies and guidelines (Charles et al., 2016). The use of the cause-effect diagram is productive as it identifies root causes and makes it easier to propose solutions to improve care and prevent the reoccurrence of the problems.
Brook, O. R., Kruskal, J. B., Eisenberg, R. L., & Larson, D. B. (2015). Root cause analysis: learning from adverse safety events. Radiographics, 35(6), 1655-1667.
Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., … & Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient safety in surgery, 10(1), 20.
Swamy, L., Worsham, C., Bialas, M. J., Wertz, C., Thornton, D., Breu, A., & Ronan, M. (2018). The 60-minute root cause analysis: a workshop to engage interdisciplinary clinicians in quality improvement. MedEdPORTAL, 14.