Discussion: Root Cause Analysis

Review the case scenario included in this week’s media resources, and examine the process flow chart, cause/effect diagram, and Pareto chart related to the case scenario.

In the scenario, the nurse manager and the director of pharmacy blame each other for the error. The facilitator (quality assurance person) asks everyone to avoid blaming and focus on applying the tools to analyze the data and get to the root cause of the error. While all of these tools contribute, for this Discussion, select one tool to analyze.

By Day 3

Post each of the following:

• Analyze the composition of the RCA team. Explain what knowledge they can contribute to the RCA.
• Describe the collaboration in the case study that led to effective problem solving. Identify the evidence you observe in the scenario that demonstrates effective collaboration and the avoidance of blaming.
• Explain the team’s process in testing for and eliminating root causes that were not contributing.
• Select one of the performance improvement charts presented in the scenario and critique its effectiveness by explaining how it contributes to identifying the root cause and determining a solution to prevent repeat medication errors.
• Identify the contributing factors, and discuss how to prevent this kind of error from occurring in the future.

Support your response with references from the professional nursing literature. Your posts need to be written at the capstone level (see checklist)

Notes Initial Post: This should be a 3-paragraph (at least 350 words) response. Be sure to use evidence from the readings and include in-text citations. Utilize essay-level writing practice and skills, including the use of transitional material and organizational frames. Avoid quotes; paraphrase to incorporate evidence into your own writing. A reference list is required. Use the most current evidence (usually ≤ 5 years old). (Refer to AWE Checklist, Capstone)

By Day 7

Read and respond to the postings of two or more of your colleagues’ who discussed different charts, identified different evidence of positive collaboration, and/or identified different contributing factors than you did. Also offer comments that ask for clarification, provide support, or contribute additional information. Offer alternative viewpoints on the cause as you see it.

Post a Discussion entry on three different days of the week.

Submission and Grading Information

Grading Criteria

Practice Experience: Stakeholder Analysis

The next step in the process is to begin identifying the challenges and impediments to implementing a quality improvement plan. In the analysis consider the individuals affected by the change as well as the cost of implementing the quality improvement plan.

By Day 4

Post a description of some of the proposed action steps for implementing improved practice, and explain where potential challenges might compromise your proposed improvement project. Describe what resources are needed for your solution, and explain whether or not those resources are cost-effective. Continue to collaborate with the selected individuals in your practice environment as needed in the development of the Practice Experience Project, and share this information with your group.

By Day 7

Read and respond to two or more of your colleagues’ postings from the Discussion question. Provide feedback on potential challenges you see might compromise the improvement project and what other resources might be more cost effective. As a member of a community of practice, help each other refine and clarify the patient-centered Practice Experience Project.

Submission and Grading Information

Grading Criteria