Root Cause Analysis

1247 words 5 pages
Root Cause Analysis Healthcare facilities that are Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredited are required to implement root cause analysis as part of their obligation. The root cause analysis team strives to assess and improve patient outcomes as specific situations occur by forming a team of experts that were involved in the situation. Cases are reviewed and processes are implemented to correct the errors that took place. Four key questions are asked, what happened, why did it happen, what can be changed to prevent it from happening again and how are we going to evaluate the change. This process takes place soon after the event so details are not forgotten. The professionals involved in the …show more content…

The hazard is due to the influx of patients into the emergency department without the adequate amount of staff. This leads to policies not being followed and ultimately the unwanted outcome for the patient.
Change in Theory and Improvement Plan
Change theory is a process that includes 3 key components to change a practice. The first is unfreezing, which is where providers need to be open to doing things differently. The transition plan is the implementation of new policies and processes. The third is freezing, which is where the new process is monitored and evaluated for effectiveness.
The first step in the improvement plan is to unfreeze the hospitals current processes. This can be done by involving associates in a plan to change. Having their input on a process change helps them to be more open to the change because they are taking ownership. In this case the issue was inadequate staffing during a high volume and high acuity time. Gathering data and evaluating the need for staffing during different times of the day and night would have to done. The transition plan could involve developing a staffing grid for the acuity and volume of patients. Evaluating the data and revising the process to ensure safe patient care would be imperative. The final step is freezing the process by making it policy. This would have to be monitored continuously


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