Analyze the composition of a root cause analysis team      in relation to effective practice

Two steps, day 3, and Day 4.

In the health care industry, root cause analysis (RCA), is a crucial process to help determine and prevent future errors. The RCA Team is made up of people from various departments, disciplines and backgrounds. They all have their own unique expertise and knowledge. The RCA team in this case included a nurse supervisor, director of the pharmacy, a quality assurance specialist, and a doctor. The quality assurance specialist and nurse manager were both involved in the actual medication error and therefore had firsthand experience of this event. A physician was also included in the process to gain insight on how medication is prescribed and dosages.

Successful RCA relies on effective collaboration. The RCA team in the scenario demonstrated successful collaboration by avoiding blame, and focusing instead on analyzing data to identify the root cause. Team members used process flow charts, cause-effect diagrams, and Pareto charts to determine contributing factors, eliminate those that did not contribute, and identify root causes. Effective collaboration was demonstrated when the team came up with a plan of improvement that targeted the cause of the error.

Pareto charts are one of several performance improvement charts included in the scenario. Pareto is a tool for identifying the factors that are most important in a given problem. It is important that the collected data be accurate and complete in order to use the Pareto Chart effectively. It is important that the RCA Team ensures all data are relevant, complete, and accurate. Pareto charts should also be used with other RCA techniques to determine the cause of the problem and create a viable solution.

In the scenario, the contributing factors for the error were unclear orders, poor communication and insufficient staff training. In order to avoid this type of mistake from happening again, the RCA Team developed an improvement program that includes the use of concise and clear medication orders, enhanced communication with staff, and increased staff training regarding medication administration. The staff’s commitment to new processes, and the efficiency of the evaluation and monitoring plan are key factors in the success of an improvement plan.

Conclusion: RCA can be used by healthcare organizations to determine the cause of an error and avoid it in the future. To ensure the success of RCA, it is important to have effective collaboration and accurate data collection. To ensure the effectiveness of their improvement plans, healthcare organizations should also create a plan for monitoring and evaluating them.