Root cause analysis

A root cause analysis (RCA) is a process used to determine why an incident or error occurred and used to develop effective solutions to prevent a reoccurrence. This process addresses three basic questions, what is the problem, why did it occur, and what can be done to prevent it (Root Cause Analysis, nd)? The root cause analysis is not designed to point fingers at individuals, its purpose is to help fix the issues or problems within systems or processes. Improvement is the goal, not to blame. RCA’s are used to ask questions and to analyze situations. RCA’s occur after a problem or issue has occurred. The multidisciplinary teams explore causes for the error. The Joint Commission requires a root cause analysis to be performed on all sentinel…

“Root Cause Analysis” is one method of determining the underlying reasons that something has occurred. This problem-solving technique is used in the work place, but it could also be used for evaluation or discovering true intentions. The analysis process involves a beginning statement. The question, “why” follows the statement and is answered. The answer is considered one cause of the initial statement, but it is not the root cause. To find the root cause, the previous answer becomes the next…

go with him. At first I was confused and angry at the fact she stated this, however, before this matter escalated I decided to use Root Cause Analysis (RCA) to establish what the actual problem was. I broke it down first into three things. 1. What happened? - An argument 2. Why? - Because I was going out with my brother and not seeing her. 3. How to make it not happen anymore - Spend more time with her. From this point on I used the 5 steps of…

An RCA is the main tool used by hospitals when investigating the cause of an error in healthcare. The Joint Commission requires a root cause analysis to be performed on every sentinel event like the one experienced by Mr. B in the given scenario. A sentinel event is an adverse event in health care delivery or other service, which either leads to or has potential to lead to catastrophic outcomes (for example, near miss), thereby often mandating initiation of emergency intervention or of…

Organizational Systems & Quality Leadership Task 2 Healthcare organizations are required by their accrediting agencies to demonstrate methods of investigating sentinel events. Root cause analysis (RCA) is a systematic approach to investigating sentinel events used by institutions accredited by the Joint Commission. Once this process helps to identify the causes of the event and a plan to correct the causes, the failure mode and effects analysis (FMEA) is used to identify and decrease the ways…

People have the tendency to stop the troubleshooting process when they arrive at the first reasonable explanation for the issue. While issues are temporarily resolved they often reoccur over time because the root cause was not resolved. In turn, further troubleshooting is required and will continue to be required until the root cause is resolved. RCA eliminates this type of redundant cycle of troubleshooting. Recommendations After determining the issue, analyzing the causal relationship and…

1. Purpose After several security incidents Greiblock Credit Union (GCU) Board of Directors needs a sound policy to address the situation. The main objective of this document is to improve the security culture of the organization. The specifications of this policy will address dynamic vulnerability analysis, intrusion detection, and incident response. This document goes into detail about what is required for a proper incidence response. 2. Scope This policy is intended to support the…

network outage on August 25th 2010. This affected several agencies and caused 13% of the file servers to fail. The failure mainly impacted the Department of Motor Vehicles and Department of taxation. Because of the outage problem, DMV couldn’t process driver’s licenses and couldn’t share data with other agencies. (1) DMV has been unable to process in-person driver’s licenses or ID cards at its 74 customer service centers. The root cause of the failure was identified as the memory card of the EMC…

1. Define Sentinel Event and give an example. An event that has adverse consequences to patients e.g. wrong site surgery or adverse reaction to a medication. A root cause analysis has to be done and reported to whoever is running the hospital. 2. When should medication reconciliation occur? Who is the primary person responsible for medication reconciliation at your site? On arrival at the ER. When there is a transition in the care on the floor Into and out of surgery Pharmacy technician in…

Root Cause Case Study Analysis – Milestone Two Michelle Norwood Southern New Hampshire University The Engstrom auto mirror plant was beset by various organization issues previously discussed in the introduction of this case study. Some of those key organizational issues included a lack of trust between employees/employer, a lack of employee motivation/morale, and a decrease in comradery among employees (Beer & Collins, 2008). These organizational issues were all centrally rooted around…