Part 3: Root Cause Analysis Report
In this section, you will create a root cause analysis. In this first paragraph, you will identify the data you would collect to determine the cause and give your rationale for choosing the data.
Probable Cause
Next, identify the probable cause. This may include process failure, human error, cultural biases, policy error, systems error, technology failure, or some other issue that may have contributed to your sentinel event. Include any or all of the following subsections in completing the probable cause portion of your report.
Human Factors
What human factors were relevant to the outcome?
Process Errors
What process errors were relevant to the outcome?
Missed Steps
Were there any steps in the process that did not occur as intended?
Equipment Performance
How did the equipment performance affect the outcome?
Other Areas
What are the other areas in the health care organization where this could happen?
Staff Performance
Did staff performance during the event meet the expectations?
Corrective Action Plan
Here, develop a corrective action plan that is geared towards eliminating future events. Explain the steps of implementing the corrective action plan. Writing at least a paragraph for each section, discuss the elements below in your response.
Risk Reduction Strategies
Being by identifying the best risk reduction strategies.
Improvement of Processes or Systems
How can the processes or systems be improved to eliminate future events?
Communication Barriers
Discuss the communication breakdown that may have contributed to the sentinel event. What barriers may have occurred to cause the breakdown in communication? Some of these may include residual intimidation, reluctance to report to a coworker, missing information at time of transition of care, etc.
Training
What training should be implemented to eliminate future events? This may include orientation, professional development, cultural competency, skills training, in-service, etc.
Equipment
What equipment should be considered to eliminate future events? This should include the technology, maintenance, and updates.
Policies and Procedures
What new or revised procedures should be considered to eliminate future events?
Monitoring Process
Describe the monitoring process that will be used to evaluate the success of the corrective action plan.
Reallocation of Budgetary Resources
Analyze the components that may require the reallocation of budgetary resources. In this paragraph or series of paragraphs, you will want to consider legal action, public relations (reputation leading to decreased revenue), equipment and supplies, training and education, patient-centered communication methods (informed consent, procedural education, patient involvement [identify or mark the location of the surgical site]), and staffing (reallocating staff, role responsibilities, hiring temporary or permanent staff).
Describe the monitoring process that will be used to evaluate the success of the corrective action plan.
