Root Cause Analysis Paper

1142 Words5 Pages
Risk Management Plan is an overarching, conceptual framework that aims to achieve the goal of patient safety and guides the healthcare organization to develop a holistic program for improving quality without compromising the patient safety initiatives. Risk management plan should be operated by creating a formal, structural and written document which should become an integral component of healthcare organization's standard business practice. In this paper, I am playing a role of a Chief Risk Management Officer for a large metropolitan not-for-profit teaching hospital and I am assigned with a case for which I will be creating a comprehensive risk management plan by performing a root cause analysis and complete risk analysis. This paper will…show more content…
Variation in performance would often produce unexpected and undesired adverse outcomes, including the occurrence or risk of a sentinel event. A root cause can be defined as one of the most fundamental reasons of failure, or a situation in which performance does not meet expectations. The word cause in the context of root cause analysis should not imply or assign responsibility or a factor to blame for a problem. Instead, the cause should focus on a positive and preventive approach and refer to the potential relationship between the responsible factors that result in a sentinel event. Root cause analysis usually performed retrospectively, and it evaluates the reasons for the bad outcomes or for sentinel events that have already occurred. In my evaluation of this case scenario, I focused on following main questions to perform a comprehensive root cause…show more content…
She just asked her name and never checked the wristband or used a barcode system or date of birth for identification.
Staffing Levels
" What are the typical staffing levels on the emergency unit and surgical unit that night?
" How many staff members were working on the unit when the error has occurred?
" How many patients were assigned at the time to the nurse who was involved in the error at the time? Though a usual number of staff members were present in the surgical unit, as described in the case, it looks like it was a busy night in the operating room and the additional staff assigned to the second case of Samantha Jones has already worked a full eight-hour shift and were overburdened.
Surgical Staff
" Who was the surgical staff that supervised the nurse who was involved in the error?
" Does the surgeon specifically oversee the identification and followed the usual surgical time-out procedure? No, none of the surgical staff or anesthesiologist were present during the identification process but they have performed brief interviews without the presence of a translator, who is much needed in this
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