Root Cause Analysis (RCA) for medication errors
Question 1 (5 points)
Prepare a Root Cause Analysis (RCA) for medication errors using the data in the attached excel sheet. RCA should include three things:
a) data collection (already collected and provided in the excel sheet)
b) data analysis (identify potential causes and root causes (prepare a frequency table and column chart showing which locations have the highest rates of medication errors then use why-why diagram to find potential causes and root causes).
c) suggested corrective or preventive action plan
Question 2 (5 points)
From January 1846 through December 1848 Semmelweis ([1860] 1983) recorded births and the number that resulted in the death of the mother at his hospital. The data is available in the attached excel sheet. Create a p chart to analyze performance. Interpret the chart. Was the system stable?
Question 3 (5 points)
provide a process in health care setting of your choice and then conduct a Failure Mode and Effect Analysis (FMEA). FMEA should include:
a) Flowchart of the process
b) A table that includes process step, failure mode, effect, severity, occurrence, detection, risk priority number (RPN), and action plan
You should analyze a minimum of three process steps.
Sample Solution
Medical error is an unfortunate reality of the healthcare industry and a topic that is continuously discussed due to its grave impact on patient care and outcomes. In a 1999 publication by the Institute of Medicine (IOM), it was highlighted that deaths resulting from medical error exceeded those attributed to motor vehicle accidents, breast cancer, or AIDS (Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors). These mistakes can result in major unwanted consequences for patients, families, and clinicians. A root cause analysis can provide a beneficial resolution for healthcare professionals and patients to further understand and combat medical error and prevent future occurrences. This activity reviews the process of a root cause analysis in medical error prevention. It highlights the interprofessional team’s role in preventing medical errors and sentinel events within the healthcare organization.
