Root Cause Analysis (RCA) is a process that is used to identify the causes of an error or accident. In the case of Mr. B death‚ a RCA is needed to determine what may have contributed to his death. A Root Cause analysis must be complete and reported to Joint Commission in the even where injury or death occurs. Sentinel event is a major adverse even that could have been prevented (Alemi‚ 2007). The sentinel event was related to respiratory arrest secondary to conscious sedation procedure. The people
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Organizational Systems and Quality Leadership Task 2 Western Governors University 03/15/2015 Root cause analysis (RCA) is one of the organized techniques that can be used as an analyzer in any events of adverse events. In health care settings the best method to track down an adverse event and find out the root cause of the problem‚ would increase the overall patient well-being outcome. The best approach to an adverse event would be to set up questions systematically from the point
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Medication errors are all too common‚ jeopardizing the safety of patients; it may be a misinterpretation of a prescription‚ not having a complete history of a patient and dispensing drugs that could interact with other drugs adversely‚ or a patient administering the medication incorrectly‚ which are all preventable. There are numerous ways of preventing medication errors; therefore‚ the Institute for Safe Medication Practices (ISMP) has recognized ten important factors that lead to errors. Anderson
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Adverse Trends and Data Management Medication Errors Kim Orta University of Phoenix Health Care Informatics HCS 482 Mary Trevino October 24‚ 2013 Data Collection Tools EMR (Electronic Medical Record) EHR (Electronic Health Record) CPOE Computerized Provider Order Entry) UOR (Unusual Occurrence Report) Electronic Health Records (EHRs) Provide complete‚ reliable access to health information Improves safety and outcomes Reduces and prevents medication errors “EHRs don’t just contain and transmit
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or even a little biased at times. My social life could be considered nonexistent at the moment‚ so there isn’t really anything to discuss in that area. I then realized that I have the perfect personal situation for applying the Root Cause Analysis tool to (Root Cause Analysis: Tracing a Problem to its Origins‚ n.d.). I recently returned from‚ and plan
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Medication Errors: Causes and Problems Reporting Student Name Grand Valley State University Medication Errors: Causes and Problems Reporting In the early morning hours of a 12-hour night shift‚ a nurse gives the patient an incorrect medication. The aspirin given was ordered for the patient in the next room. Medication errors are common in the hospital setting and especially by a nurse who is fatigued from working a 12-hour shift. In the situation described
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Medication errors are made time and time again by health care professionals all around the world. Although these errors are accidental they can be life-threatening. There are several types of medication errors that can occur‚ such as prescribing errors‚ transcription errors‚ dispensing errors‚ administration errors‚ and monitoring errors (Clayton and Willihnganz‚ p. 73). In this reading‚ it will specifically talk about an administration error and how it ended the life of a mother-of-four. Arsula
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Root Cause Analysis (RCA) is a tool to find the root factor in a failure of a system or of a process. In a RCA‚ we always want to establish the chain of events first. Reviewing the second scenario we have a Mr. B‚ the patient‚ Dr. T‚ RN J and an LPN with no initial. Mr. B comes into the ER with a hip dislocation at 15:30. He is triaged‚ assessed‚ history obtained‚ placed in ER room and the ER physician is updated on patient status and history. Mr. B’s vitals at this time are B/P 120/80‚ HR 88
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ROOT CAUSE: In this case‚ we believe that there are three main root causes from the management of this company‚ especially in packaging department. The first main one is cohesiveness limited the productivity in packaging department. Cohesiveness for packing department was existent and had become somewhat negative. Employees were mimicking the bad behavior of one another and were failing to get anywhere production wise. Packing department seemed to be small knit group and they were able to complete
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Prevention of Medication Errors Medication administration is one of the highest risks in health care‚ and the errors can occur in many ways. Medication errors occur at points of transition in care: admission to the hospital‚ transfer from department to another‚ and at discharge home or to another facility (Taylor‚ Lillis‚ & LeMone‚ 2015). It is at these times we see the greatest room for errors from communication between other departments and facilities. In 1999‚ medication errors were the 8th leading
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