Root Cause Analysis and Quality Improvement in Healthcare: Addressing Never Events
This paper discusses root cause analysis and strategies for quality improvement in healthcare, focusing on preventing never events.
Ethan Wilson
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Root Cause Analysis and Quality Improvement in Healthcare: Addressing
Never Events
Conduct a Root Cause Analysis (RCA) of a never event in a healthcare setting, focusing on
identifying system failures and human errors that contributed to the adverse outcome. Using
Kurt Lewin’s Change Management Theory, propose an improvement plan to prevent similar
incidents in the future. Additionally, apply Failure Modes and Effects Analysis (FMEA) to
assess the risks associated with the current process and recommend improvements.
Your response should be 1,500–2,000 words and must include:
• A detailed Root Cause Analysis (RCA) identifying key contributing factors.
• An explanation of errors or hazards that led to the event.
• A structured improvement plan based on Lewin’s Change Management Theory.
• An application of Failure Modes and Effects Analysis (FMEA) to evaluate risks and
suggest process improvements.
• Proper citations and references following APA format.
Never Events
Conduct a Root Cause Analysis (RCA) of a never event in a healthcare setting, focusing on
identifying system failures and human errors that contributed to the adverse outcome. Using
Kurt Lewin’s Change Management Theory, propose an improvement plan to prevent similar
incidents in the future. Additionally, apply Failure Modes and Effects Analysis (FMEA) to
assess the risks associated with the current process and recommend improvements.
Your response should be 1,500–2,000 words and must include:
• A detailed Root Cause Analysis (RCA) identifying key contributing factors.
• An explanation of errors or hazards that led to the event.
• A structured improvement plan based on Lewin’s Change Management Theory.
• An application of Failure Modes and Effects Analysis (FMEA) to evaluate risks and
suggest process improvements.
• Proper citations and references following APA format.
RTT1 Task 2
Never events are serious medical errors that are often preventable. When such events transpire, it
is necessary to fully assess the situation so that these errors can be prevented in the future. Root
cause analysis (RCA) is a tool employed by healthcare facilities to analyze adverse events and
the systems that lead to them.
A. Root Cause Analysis
“A central tenet of RCA is to identify underlying problems that increase the likelihood of errors
while avoiding the trap of focusing on mistakes by individuals” (AHRQ, 2012). The emphasis of
RCA is on error prevention. It is a structured process of gathering data regarding the event,
analyzing the information, and finding solutions to the problems to prevent reoccurrences. A
team consisting of the charge nurse, a physician, a respiratory therapist, a pharmacist, hospital
administrators, and patients not involved in the case is assembled to work through the process.
The team begins by interviewing patients and staff involved to gather as much vital information
as possible. Once all necessary information is compiled, the team works together to get to the
root(s) of the problem.
In the case of Mr. B, there were multiple issues that led to the adverse event as opposed to one
root problem. In the process of defining the problem, several causal factors were identified. The
error was a result of both facility and human error. Mr. B, a 67-year-old patient, presented to the
small, six-room, rural hospital ED due to severe pain in his left hip following a fall. In his quest
for care, he came across some hurdles that eventually led to his death. Amongst one of the many
issues that led to complications was the fact that the hospital was short staffed with only one RN,
Nurse J., and one LVN on shift. There was also only one ED physician, Dr. T. At the time of Mr.
B’s arrival, two other patients were being cared for. As Mr. B was being treated, a patient that
was in respiratory distress was being admitted. Meanwhile, the two patients that had been seen
earlier were awaiting discharge instructions and the ED waiting room had also become much
busier. There was additional backup staff present (including a respiratory therapist) that could
have been called upon for help, yet they never were. The charge nurse or nurse supervisor could
have stepped in at this point to provide additional help. A lack of present nursing staff and
support can lead to unfavorable patient outcomes, as is the case with Mr. B. Additionally, the
staff on duty could have lacked training regarding protocols or their training could have been out
of date.
Never events are serious medical errors that are often preventable. When such events transpire, it
is necessary to fully assess the situation so that these errors can be prevented in the future. Root
cause analysis (RCA) is a tool employed by healthcare facilities to analyze adverse events and
the systems that lead to them.
A. Root Cause Analysis
“A central tenet of RCA is to identify underlying problems that increase the likelihood of errors
while avoiding the trap of focusing on mistakes by individuals” (AHRQ, 2012). The emphasis of
RCA is on error prevention. It is a structured process of gathering data regarding the event,
analyzing the information, and finding solutions to the problems to prevent reoccurrences. A
team consisting of the charge nurse, a physician, a respiratory therapist, a pharmacist, hospital
administrators, and patients not involved in the case is assembled to work through the process.
The team begins by interviewing patients and staff involved to gather as much vital information
as possible. Once all necessary information is compiled, the team works together to get to the
root(s) of the problem.
In the case of Mr. B, there were multiple issues that led to the adverse event as opposed to one
root problem. In the process of defining the problem, several causal factors were identified. The
error was a result of both facility and human error. Mr. B, a 67-year-old patient, presented to the
small, six-room, rural hospital ED due to severe pain in his left hip following a fall. In his quest
for care, he came across some hurdles that eventually led to his death. Amongst one of the many
issues that led to complications was the fact that the hospital was short staffed with only one RN,
Nurse J., and one LVN on shift. There was also only one ED physician, Dr. T. At the time of Mr.
B’s arrival, two other patients were being cared for. As Mr. B was being treated, a patient that
was in respiratory distress was being admitted. Meanwhile, the two patients that had been seen
earlier were awaiting discharge instructions and the ED waiting room had also become much
busier. There was additional backup staff present (including a respiratory therapist) that could
have been called upon for help, yet they never were. The charge nurse or nurse supervisor could
have stepped in at this point to provide additional help. A lack of present nursing staff and
support can lead to unfavorable patient outcomes, as is the case with Mr. B. Additionally, the
staff on duty could have lacked training regarding protocols or their training could have been out
of date.
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Healthcare