Root Cause Analysis (RCA) is a process designed to analyze and identify the underlying factors that directly contributes towards the cause of major events or failure of system. RCA events are utilize typically to directly guide the changing processes, environment and human behavior in order to reduce or prevent the adverse probability for any future event occurrence. Root Cause Analysis utilizes the wide variety of different industries for the last two decades. RCA origin was firstly introduce in the engineering field, which than quickly become the standard management tool in other fields. The introduction of the RCA was recently added in the armamentarium of the health care system in the year 1999 against the growing sentinel event standards (Strategies and tips, 2002).
Sentinel events are termed as a subset of adverse medical events. Sentinel events are considered as a sending signal or warning that requires immediate attention. Determined event are such sort of sentinel events when a Root Cause Analysis assembled team is expected to review the case and develop to deliver an action plan to the Hospital Leadership within the 45 calendar days of the event notification. This root cause analysis team is multidisciplinary, the members being members of the relevant departments, but not involved with the event. A facilitator from the legal office arranges meetings, keeps minutes and writes up the final report.
Case procedures for RCA
In the case when Mr. B event of the sentinel occurred, the responsibility of Nurse J should report immediately to the present medical officer on the floor for quick concern about the case .
Nurse J, should immediately inform the attending physician when the variance involves Mr. B in his medical situation.
Mr. B condition got serious within the time of his admittance in the hospital, so the hospital shall be responsible for completing a Sentinel event report.
Nurse J, identified the event occurrence of Sentinel situation of Mr. B, so nurse shall be accountable for commencing the complete Variance Report Form prior to the end of her scheduled shift of duty.
Completion of the Sentinel Event Report shall be done by the reporting nurse at the time of the event occurred, and the same nurse will submit the report to her immediate supervisor. In case the availability of the supervisor is doubtful; the report shall be submitted to the Emergency Medical Officer on duty.
As soon as the sentinel event is reported, the present doctor shall be the one who needs to decide about how to analyze the root because analysis should be conducted. Usually Event Root-Cause Analysis shall be considered when an occurrence meets any of the following criteria:
The involvement of the occurrence of unanticipated death or major permanent loss of function.
The occurrence is associated with significant deviation from the usual process for providing health care services or managing the organization.
The case of Mr. B is relevantly the carelessness of undermined and had significant potential for the complete confidence of patients over their ...