Introduction. Health care organizations are capitalizing on the root cause analysis (RCA) route to determine the focal cause of adverse events within their facilities. First developed as a tool used in the engineering sector, RCAs have been extended to health care in many ways and have proved to be highly effective in improving facility performance and safety. This paper provides a more in-depth look into RCAs while also showing one particular case study. RCA defined. The World Health Organization (2012) characterizes an RCA as a process that explores and identifies possible factors correlating to an incident by asking questions such as, "What occurred?", "Why it occurred?", and "How can it be prevented?". Health care organizations and risk
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The Department of Health and Human Services (2012) defines a clinical incident as an event that could or did lead to an unexpected, unintended harm to an individual, financial loss, physical or emotional damage, and/or a complaint. In the case study, "Getting to the Root of the Matter", a 65-year-old patient with a significant handful of health problems arrived at an emergency department complaining of shortness of breath. The incident in question centers on the patient receiving a higher dosage of vasopressin, a water retention hormone. Fortunately, the providers discovered the medical error and prevented any further overdose, consequently leading the patient 's medical state improving. Although the patient seemingly recovered, a medial mistake occurred, possibly prompting a root cause analysis. The providers may begin to ask, "what if the dosage was much higher or lower?" or "what if the dosage was a much stronger medication?" possibly leading to a more tragic outcome. The incident here would fall under The Joint Commission 's (TJC) category of "or risk thereof" occurrence for a sentinel event. These unexpected events include variations for which a recurrence would cause an impactful possibility of a serious adverse result (TJC, 2011). Immediate investigation and response occurred when the health care providers realized the vasopressin overdose. In order to prevent a situation similar and/or possibly worse-off, the organization may recommend …show more content…
A medical error occurred during the 65-year-old man 's health care treatment. A pro-investigation argument may reference the infamous report by the Institute of Medicine (IOM) for validation. The report concludes that nearly 45,000 to 100,000 patients die because of said medical errors each year (IOM, 1999). Aforementioned, the patient 's treatment thankfully did not end in tragedy, but the organization must begin to wonder what might have happened if the error occurred elsewhere or to a higher, more threatening degree. If further investigation is halted, and a future instance occurs similar to this one but ends in tragedy, then the organization may face a harsher
The Department of Health and Human Services (2012) defines a clinical incident as an event that could or did lead to an unexpected, unintended harm to an individual, financial loss, physical or emotional damage, and/or a complaint. In the case study, "Getting to the Root of the Matter", a 65-year-old patient with a significant handful of health problems arrived at an emergency department complaining of shortness of breath. The incident in question centers on the patient receiving a higher dosage of vasopressin, a water retention hormone. Fortunately, the providers discovered the medical error and prevented any further overdose, consequently leading the patient 's medical state improving. Although the patient seemingly recovered, a medial mistake occurred, possibly prompting a root cause analysis. The providers may begin to ask, "what if the dosage was much higher or lower?" or "what if the dosage was a much stronger medication?" possibly leading to a more tragic outcome. The incident here would fall under The Joint Commission 's (TJC) category of "or risk thereof" occurrence for a sentinel event. These unexpected events include variations for which a recurrence would cause an impactful possibility of a serious adverse result (TJC, 2011). Immediate investigation and response occurred when the health care providers realized the vasopressin overdose. In order to prevent a situation similar and/or possibly worse-off, the organization may recommend …show more content…
A medical error occurred during the 65-year-old man 's health care treatment. A pro-investigation argument may reference the infamous report by the Institute of Medicine (IOM) for validation. The report concludes that nearly 45,000 to 100,000 patients die because of said medical errors each year (IOM, 1999). Aforementioned, the patient 's treatment thankfully did not end in tragedy, but the organization must begin to wonder what might have happened if the error occurred elsewhere or to a higher, more threatening degree. If further investigation is halted, and a future instance occurs similar to this one but ends in tragedy, then the organization may face a harsher