Root Cause Analysis AHRQ Patient Safety Network

Root Cause Analysis AHRQ Patient Safety Network

Root cause analysis (RCA) is a structured method used to analyze serious adverse events. Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in healthcare. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals. RCA thus uses the systems approach to identify both active errors (errors occurring at the point of interface between humans and a complex system) and latent errors (the hidden problems within healthcare systems that contribute to adverse events). It is one of the most widely used retrospective methods for detecting safety hazards (Retrieved April 17, 2015 from Root Cause Analysis | AHRQ Patient Safety Network ) .

A cross-sectional study on the relationship between utilization of root …

Root cause analysis (RCA) has been a Joint Commission mandated tool for examining sentinel events since 1997. Ho…

https://psnet.ahrq.gov/resources/resource/25496

Root Cause Analysis | AHRQ Patient Safety Network

Initially developed to analyze industrial accidents, root cause analysis is now widely deployed as an error anal…

https://www.psnet.ahrq.gov/primers/primer/10

Glossaries | AHRQ Patient Safety Network

https://psnet.ahrq.gov/glossary/activeerror

Detection of Safety Hazards | AHRQ Patient Safety Network

Health care organizations use a variety of established and emerging methods to prospectively identify safety haz…

https://psnet.ahrq.gov/primers/primer/24

Systems Approach | AHRQ Patient Safety Network

Medicine has traditionally treated errors as failings on the part of individual providers, reflecting inadequate…

https://psnet.ahrq.gov/primers/primer/21

Glossaries | AHRQ Patient Safety Network

https://psnet.ahrq.gov/glossary/latenterror

Directions:

1. Students will identify a current problem or issue occurring on a nursing unit or within a healthcare organization.

2. Students will identify at least five (5) stakeholders and interview them to determine the root causes of the problem.

3. The student will write a three to four page paper describing the issue and the results of the interviews. Paper will be in APA 6th ed. Format.

4. The student will provide a complete Root Cause Analysis graph.

Resources:

· Root Cause Analysis for Healthcare – https://www.jcrinc.com/assets/1/14/EBRCA15Sample.pdf

· Root Cause Analysis Sample Video– Medication Errors – https://www.youtube.com/watch?v=ESrTr08fLB4

· Root Cause Analysis Samples and Templates – EXAMPLE PROBLEMS & RCA TEMPLATES

EXAMPLE PROBLEMS & RCA TEMPLATES

RCA examples with evidence, problem statement, cause and effect, incident timeline, solutions, and final report

https://www.sologic.com/en-us/resources/example-problems

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.