Application of Root Cause Analysis

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As you have examined in this course, errors and mishaps, although not frequent, do occur in health services organizations. While the aim is to deliver effective and quality care, errors due to systems processes or inefficient system checks still exist. As a current or future health care administration leader, applying process tools to analyze and determine the causes of such errors will likely impact initiatives aimed at fostering health care quality and safety.

For this Assignment, review the resources for this week that are specific to RCA. Reflect on the AHRQ article regarding factors that may lead to latent error and the New York Times article regarding the doctor who removed the wrong limb from a patient. Think about recommendations you might make to prevent errors such as these from occurring in your health services organization.

The Assignment: (3–4 pages)

  • Briefly summarize the salient facts of the New York Times article.
  • Using the AHRQ table regarding factors that may lead to latent error, assess how each factor might have contributed to the wrong-limb surgery.
  • Qualitatively assess how much each factor contributed to the error.
  • Provide recommendations that you believe would present such an event from occurring again, and explain why you made these recommendations. Be specific and provide examples.

RESOURCES

Ross, T. K. (2014). Health care quality management: Tools and applications. San Francisco, CA: Jossey-Bass.

  • Chapter 5, “Root Cause Analysis” (pp. 161–216)

Agency for Healthcare Research and Quality. (2014). Root cause analysis. Retrieved from https://psnet.ahrq.gov/primers/primer/10/root-caus…

Associated Press. (1995, September 17). Doctor who cut off wrong leg is defended by colleagues. The New York Times. Retrieved from http://www.nytimes.com/1995/09/17/us/doctor-who-cu…

Wu, A. W., Lipshutz, A. K. M., & Pronovost, P. J. (2008). Effectiveness and efficiency of root cause analysis in medicine. Journal of the American Medical Association, 299(6), 685–687.
Note: Retrieved from the Walden Library databases.

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