Discussion: Root Cause Analysis
Discussion: Root Cause Analysis
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 (see checklist) Notes Initial Post: This should be 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). Discussion: Root Cause Analysis

ORDER A PLAGIARISM-FREE PAPER HERE

Analyze the composition of the RCA team. Explain what knowledge they can contribute to the RCA.

The RCA team is comprised of three member who include a risk manager, staff nurse, and pharmacy technician. The risk manager is knowledgeable in the identification, measurement and evaluation of the different risks associated with the problem. The staff nurse presents the nursing and user perspective to the problem. The pharmacy technician offers knowledge on the information technology systems that support medication management (Yoder-Wise, 2013). Discussion: Root Cause Analysis

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.
The case study identifies four unique collaborative elements that helped with problem solving. Firstly, it utilized differences by ensuring that the RCA team members represented different perspectives that were then pooled for a combination perspective. Secondly, all the team members were involved through getting their opinions. Thirdly, the members were not afraid to talk openly even if this would have resulted in conflict. Finally, the risk manager acted as the facility to guide the discussion, diffuse tension and address conflicts for constructive discussion (Yoder-Wise, 2013).

Explain the team’s process in testing for and eliminating root causes that were not contributing.
The team applied a four-step process in testing for and eliminating the root causes. The first step was to identify the possible casual factors. The second step was to identify the actual root causes from among the possible casual factors. Unlike the causal factors, addressing the root cause eliminates the problem. The third step was to identify the challenges that the team can address as being within its scope. The final step was to prioritize and address the challenges within the scope of the team’s mandate (Bowerman & van Wart, 2915).

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.
A fish bone diagram is a useful tool for conducted cause and effect analysis. It helps with considering all likely causes instead of considering the most obvious causes. This is important for identifying the root cause and helping with completely solving the problem instead of addressing part of it so that it does not present a concern anymore. To be more precise, it helps with discovering the root cause of the problem, eliminating bottlenecks in the analysis process, and identifying where and why a process fails (Robbins & Judge, 2015). Discussion: Root Cause Analysis

Identify the contributing factors, and discuss how to prevent this kind of error from occurring in the future.
Based on the discussion by the RCA team and results of the Pareto Chart, six contributing factors were identified. The first contributing factor is defective scanners, and this can be addressed through using working scanners. The second factor is look-alike medication labeling, and this can be addressed through using unique labels for each medication. The third factor stress and understaffing among personnel that causes them not to countercheck the filled prescriptions. This can be addressed through engaging more personnel. The fourth factor is manual entry with internal entry number that presents opportunities for entry errors. This can be addressed through using automatic scanners and readers. The fifth factor is absence of phone and voicemail resources in the pharmacy, to be addressed through providing the resources as required. The final factor is knowledge deficits among personnel, to be addressed through improving knowledge levels.

References

Bowerman, K. & van Wart, M. (2015). The business of leadership: an introduction. New York, NY: Routledge.

Robbins, S. & Judge, T. (2015). Organizational behavior (16th ed.). Boston, MA: Pearson.

Yoder-Wise, P. (2013). Leading and managing in nursing (5th ed.). Amsterdam: Elsevier Health Sciences.

Cause-effect_diagram

Medication_error_Analysis

WAL_NURS4220_04_A_EN-CC

Medication_Administration

Discussion: Root Cause Analysis