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.
Read and respond to the postings of two or more of your colleagues’ who discussed different charts, identified different evidence of positive collaboration, and/or identified different contributing factors than you did. Also offer comments that ask for clarification, provide support, or contribute additional information. Offer alternative viewpoints on the cause as you see it.
attached in files are the case scenario and graphs to go by to help understand the response of discussion a and b and how to respond to them
discussion a and b are to be responded to
Expert Solution Preview
Introduction:
Root cause analysis is a critical tool used in the healthcare industry to identify the underlying cause(s) of medical errors and other adverse events. It is essential to conduct a thorough analysis to prevent future occurrences of similar events. In this discussion, we will analyze the case scenario, process flow chart, cause/effect diagram, and Pareto chart related to the case scenario and select one tool to analyze. We will also respond to the postings of two or more colleagues who discussed different charts and identified different contributing factors.
Answer:
After analyzing the case scenario and related tools, I have decided to select the cause/effect diagram to analyze. The cause/effect diagram, also known as a fishbone diagram, is a tool that helps to identify the possible causes of a problem. In this case, the problem is a medication error that occurred in the hospital, and we need to identify the root cause(s) to prevent future occurrences. The cause/effect diagram will help us in identifying all possible causes and sub-causes, which will help us to develop effective strategies to prevent future errors.
Based on the diagram, I identified the following primary causes of the error: communication breakdown, inadequate training, and inadequate system design. The sub-causes include lack of effective communication between the nurse manager and the pharmacy director, lack of standard training for the nurses and pharmacy staff, and lack of a system to detect medication errors before they occur.
To prevent future errors, the hospital management needs to address these root causes. They should develop effective communication strategies between the departments, provide adequate training to the nurses and pharmacy staff, and implement an automated medication dispensing system to detect potential errors.
In conclusion, the cause/effect diagram is a powerful tool that helps in identifying the root cause(s) of an error. By identifying the root cause(s) of the medication error, we can develop effective strategies to prevent future errors from occurring.
