Root Cause Analysis Case Study

Review the case at the U.S. Department of Health and Human Services, Agency for Healthcare Quality and Research, “Getting to the Root of The Matter” at https://psnet.ahrq.gov/webmm/case/98/getting-to-the-root-of-the-matter

Prepare a 4-page paper that responds to the following:
1. Define a root cause analysis and when it is used.
2. In the case study identify the incident and explain the problem that might trigger a root cause analysis.
3. Do you agree that the problem should not be investigated? Explain why or why not?
4. Discusses the goals and limitations of root cause analysis;
5. Outline the steps to conduct a root cause analysis.

What is a RCA and when is it Used The acronym RCA is defined as the root cause analysis, which is performed
This organization became known as the Patient Safety Organizations (PSOs), and they determine the safety information that is disclosed pertaining to the patient. Consequently, in 1995 the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), was formed to be the surveillance of healthcare quality control. Initially, the JCAHO encouraged reporting of sentinel events but it was not a requirement. Hence fore, today they have a Sentinel Event Database, which healthcare facility can access to perform voluntary reports of sentinel events. This databased was developed to report serious incidents such as death, loss of function, or loss of
U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality; Patient Safety Primers. http://www.psnet.ahrq.gov/primer.aspx?primerID=13
Patient Safety. Minnesota Department of Health Web site. Available at: http://www.health.state.mn.us/patientsafety/ae/index.html
Rule R380-200. Patient Safety Sentinel Event Reporting. The Utah Administrative Code. (March 2013) Patient Safety Initiatives. Utah Department of Health Web site. Available at: http://www.rules.utah.gov/publicat/code/r380/r380-200.htm
Root Cause Analysis. Agency for Healthcare Research and Quality. October 2012 http://www.psnet.ahrq.gov/primer.aspx?primerID=10
Joint Commission for the Accreditation of Healthcare Organizations' " Sentinel Events” – January 2011" found at http://www.jointcommission.org/assets/1/6/2011_CAMLTC_SE_(2).pdf
Patient Safety States. National Academy for State Health Policy