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Assignment Contenthttps://psnet.ahrq.gov/webmm/case/314/multifactori…Read the Multifactorial Medication Mishap case study and the commentary that follows.Complete the root cause analysis worksheet to analyze the caseWrite a 525 word-summary in which you:Explain why a root cause analysis was appropriate for this situation.Analyze the impact of using tools like RCA, FMEA, and PDSA on the quality and safety of patient care. (YOU MAY CHOOSE THE TOOLS YOU LIKE TO USE)Cite a minimum of two peer-reviewed or evidence-based sources published within the last five years to support your summary in an APA-formatted reference page.
_root_cause_analysis_worksheet_wk4.docx

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Root Cause Analysis Worksheet
NSG/468 Version 1
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University of Phoenix Material
Medication Mishap Root Cause Analysis Worksheet
Complete the table below to analyze the Week 4 case study. The analysis questions in the table have been adapted from The Joint Commission’s
Root Cause Analysis and Action Plan Framework you reviewed in this week’s learning activity.
Analysis Questions
Considerations
What was the intended process flow?
List the relevant process steps as defined
by the policy, procedure, protocol, or
guidelines in effect at the time of the event.
Were there any steps in the process
that did not occur as intended?
Explain in detail any deviation from the
intended processes.
What human factors were relevant to
the outcome?
Staff-related human performance factors
such as fatigue, distraction, etc.
How did the equipment performance
affect the outcome?
Consider all medical equipment and
devices.
What controllable environmental
factors directly affected this outcome?
Consider things such as overhead paging
that cannot be heard or safety or security
risks.
What uncontrollable external factors
influenced this outcome?
Factors the organization cannot change
Were there any other factors that
directly influenced this outcome?
Internal factors
What are the other areas in the
organization where this could happen?
List where the potential exists for similar
circumstances.
Root Cause Analysis Findings
Source: The Joint Commission ROOT CAUSE ANALYSIS AND ACTION PLAN FRAMEWORK TEMPLATE. Revised 3/22/13.
Accessed 10/07/2015: http://www.jointcommission.org/framework_for_conducting_a_root_cause_analysis_and_action_plan/
Root Cause
(Y/N)
Root Cause Analysis Worksheet
NSG/468 Version 1
Considerations
Root Cause Analysis Findings
Root Cause
(Y/N)
Was the staff properly qualified and
currently competent for their
responsibilities at the time of the
event?
Evaluate processes in place to ensure staff
is competent and qualified.
N/A
N/A
How did actual staffing compare with
ideal levels?
Include ideal staffing ratios and actual
staffing ratios along with unit census.
N/A
N/A
What is the plan for dealing with
staffing contingencies?
What the organization does during a
staffing crisis
N/A
N/A
Were such contingencies a factor in
this event?
If alternative staff used, verify competency
and environmental familiarity.
N/A
N/A
Did staff performance during the event
meet expectations?
To what extent did staff perform as
expected within or outside of the
processes?
To what degree was all the necessary
information available when needed?
Accurate? Complete? Unambiguous?
Patient assessments were complete,
shared and accessed by members of the
treatment team
To what degree was the
communication among participants
adequate for this situation?
Analysis of factors related to team
communication and communication
methods
Was this the appropriate physical
environment for the processes being
carried out for this situation?
Proactively manage the patient care
environment.
What systems are in place to identify
environmental risks?
Were environmental risk assessments in
place?
What emergency and failure-mode
responses have been planned and
tested?
What safety evaluations and drills have
been conducted?
How does the organization’s culture
support risk reduction?
Does the overall culture encourage change,
suggestions, and warnings from staff
regarding risky situations or problematic
areas?
N/A
N/A
Analysis Questions
Source: The Joint Commission ROOT CAUSE ANALYSIS AND ACTION PLAN FRAMEWORK TEMPLATE. Revised 3/22/13.
Accessed 10/07/2015: http://www.jointcommission.org/framework_for_conducting_a_root_cause_analysis_and_action_plan/
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Root Cause Analysis Worksheet
NSG/468 Version 1
Analysis Questions
Considerations
What are the barriers to
communication of potential risk
factors?
Describe specific barriers to effective
communication among caregivers.
How is the prevention of adverse
outcomes communicated as a high
priority?
Describe the organization’s adverse
outcome procedures.
How can orientation and in-service
training be revised to reduce the risk of
such events in the future?
Describe how orientation and ongoing
education needs of the staff are evaluated.
Was available technology used as
intended?
Such as: CT scanning equipment,
electronic charting, medication delivery
system, tele-radiology services
How might technology be introduced or
redesigned to reduce risk in the future?
Describe any future plans for
implementation or redesign.
Root Cause Analysis Findings
Root Cause
(Y/N)
N/A
N/A
Source: The Joint Commission ROOT CAUSE ANALYSIS AND ACTION PLAN FRAMEWORK TEMPLATE. Revised 3/22/13.
Accessed 10/07/2015: http://www.jointcommission.org/framework_for_conducting_a_root_cause_analysis_and_action_plan/
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