Root Cause Analysis In Healthcare

Risk Management Plan is an overarching, conceptual framework that aims to achieve the goal of patient safety and guides the healthcare organization to develop a holistic program for improving quality without compromising the patient safety initiatives. Risk management plan should be operated by creating a formal, structural and written document which should become an integral component of healthcare organization's standard business practice. In this paper, I am playing a role of a Chief Risk Management Officer for a large metropolitan not-for-profit teaching hospital and I am assigned with a case for which I will be creating a comprehensive risk management plan by performing a root cause analysis and complete risk analysis. This paper will

Variation in performance would often produce unexpected and undesired adverse outcomes, including the occurrence or risk of a sentinel event. A root cause can be defined as one of the most fundamental reasons of failure, or a situation in which performance does not meet expectations. The word cause in the context of root cause analysis should not imply or assign responsibility or a factor to blame for a problem. Instead, the cause should focus on a positive and preventive approach and refer to the potential relationship between the responsible factors that result in a sentinel event. Root cause analysis usually performed retrospectively, and it evaluates the reasons for the bad outcomes or for sentinel events that have already occurred. In my evaluation of this case scenario, I focused on following main questions to perform a comprehensive root cause

I focused on each area of the healthcare organization and role of each person in the causation of the error and created a risk management plan by answering the below-mentioned questions as follows:

Patient Identification Process

" What specific patient identification processes and protocols are used?

" Did the hospital staff verify the patient's identity?

" Was the patient identified by a 3-point identification using a bar-coded wristband or any other means?

Though both patients' problems were correctly identified in the emergency room, a proper protocol or identification process was not followed in the operation room holding area by the nurse. She just asked her name and never checked the wristband or used a barcode system or date of birth for identification.

Staffing Levels

" What are the typical staffing levels on the emergency unit and surgical unit that night?

" How many staff members were working on the unit when the error has