Discussion: 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.
Notes Initial Post: This should be a 3-paragraph (at least 450 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).
* ATTACHED IN THE FILE ARE THE CHARTS TO ASSIST IN ANSERWING THE QUESTION AND A NARRATIVE COPY OF THE CASE SCENARIO
Discussion: 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 scena
RCA Dramatization 1 RCA Dramatization 1 Program Transcript FEMALE SPEAKER: Medication errors are a plague. As in the case you’re ab out to see, it involves a 20-bed medical treatment facility called Downtown Medical. Everyone at the facility had believed that medication errors would decli ne there for two reasons. First, they started utilizing computerized physician or der entry, or CPOE, in conjunction with online nursing documentation, NDMR. And als o, they began employing barcoded medication administration. But after four years of using these tools, there are still issues. Another medication error has occurred. In fact, there have been many, constituting a signif icant pattern and trend. So an RCA team has been assembled. The team is compri sed of me — I’m the risk manager– Pamela Brown, the staff nurse, and Matthew White, our pharm tech. We called our first meeting. And this is what hap pened. This medication error could have easily happened to anyone in our hospit al. Our responsibility is to prevent it from happening again. This is the eighth medication error this month. We have to determine the cause of the errors. FEMALE SPEAKER: I agree, Linda. But if I could be direct for a second, I think if pharmacy got their act together, we wouldn’t be having any of these prob lems. MALE SPEAKER: You don’t want to start pointing fingers, Pam. FEMALE SPEAKER: Look, we’ve all had our share of problems with this issu e. And we’re all on the hook for patient safety. We have to get at the root cause of what’s happening here. And that’s why I picked you for this team. I need you to keep an open mind on this. FEMALE SPEAKER: You’re right. I’m sorry I made that comment, Matt. MALE SPEAKER: No problem. FEMALE SPEAKER: The thing is my nurses are always so stressed and understaffed. We hear complaints all the time about patient safety, like it’s all on us. The truth is the pharmacy at Downtown Medical really is quite helpfu l. I mean that. MALE SPEAKER: Thank you. What Pam said, the same thing is true in the pharmacy. I’ve been a pharm tech here for 10 years, and it feels like we ‘re always understaffed. We never seem to have enough people. Maybe we should start by talking about that? © 2016 Laureate Education, Inc. 1 RCA Dramatization 1 FEMALE SPEAKER: That’s a good idea, but I thought we’d look at the overa ll process first, from start to finish. Have either of you ever developed a process flow chart? FEMALE SPEAKER: I’ve read about them. But I’ve never done one. MALE SPEAKER: Well, I was in on the last IT install. We did process flow charting for that. FEMALE SPEAKER: OK. So what I thought we’d do is use this first meeting to scope out how the process works. We’ll write it out. After that, you should take i t back to your departments and use it to conduct interviews with those who were involved with the actual medication error incident. And then we’ll use i t on our next meeting. Is that OK with you? MALE SPEAKER: Works for me. FEMALE SPEAKER: Yeah, me, too. FEMALE SPEAKER: OK. Great. Then the next step will be to identify indivi duals we’ll want to interview to determine exactly what happened with the medi cation error. We’ll be constructing a cause effect diagram, which is a qualitat ive tool done with some brainstorming after the interviews. And we’ll be analyzin g last years medication errors as to primary cause. We’ll need weekly meetings and some ground rules to pull this off. Are you game? The meeting got off to a bumpy start, but once we focused on working tog ether, the RCA team members were true to their word. They kept an open mind and agreed to meet on a regular basis to get the work done. In no time, they helped me complete the process flow chart, a cause and effect diagram, and a co mplete analysis of a year’s worth of medication errors, which were plotted on a Pareto chart. We were on our way. RCA Dramatization 1 Additional Content Attribution FOOTAGE: GettyLicense_113439900_h12.mov Chayne Gregg/Creatas Video/Getty Images © 2016 Laureate Education, Inc. 2