Root Cause Analysis

Instructions

The death of a patient (as described in the Real Life Scenario (text Chapter 11, pages 233-234) is always classified as a sentinel event. The Joint Commission requires the organization to do a root-cause analysis when such an event occurs. The purpose of the analysis is to discover what processes led to the occurrence. In this assignment, students will use the “cause and effect fishbone diagram” which is the most commonly used technique used in a root cause analysis. This exercise will give students experience in conducting the root cause analysis that is used in actual hospital situations.

Instructions

• After reading Chapter 11 in the text, review the Real Life Scenario on pages 233-234 about Dr. Low and his patient Mrs. Yu.
• Your assignment is to complete the Root Cause Analysis document attached.
• There is no outside research required for this assignment; all the information you need is included in Chapter 10.
• This is a template model for analyzing a sentinel event, so not all of the questions will apply to the case scenario that the students are asked to analyze.
• How to fill out the template for Root Cause Assignment:
  • Columns 1 & 2 (titled “Level of Analysis”) are just for guidance.
  • Students should focus on Column 3’s Questions, answering them in the “Findings” column 4.
  • Columns 5-7 for Root Cause/Ask Why and Take Action can be used to indicate whether the findings described in the “Findings column” are part of the root cause, whether we need more information to answer the question, or whether we need to take some action.
  • Students would put a check mark or a Y/N in each box to say whether the findings are part of the root cause/ask why (more info)/take action.
  • For any Findings that are marked “take action” in column 7, students should suggest a Risk Reduction Strategy on the last page of the template.
• Again, this is a template so it’s possible that not every question will apply to the case scenario. Students should complete as many of the questions as they can be based on the information provided in the case scenario.
• Your submission should include a cover page that summarizes your findings, plus the completed Root Cause Analysis document.