Identify discrepancies between identified practice standards and current practice that may adversely impact patient outcomes. 

Root Cause Analysis Scholarly Writing Paper

Purpose: The nurse participates in establishing, maintaining, and improving the healthcare environment, through utilization of a Root Cause Analysis to correct a clinical health problem.

Objectives: 

1. 1. Utilize the root cause process to identify a health care problem within the organizational structure.
2. Determine the relationship between different root causes for a problem.
3. Discuss improvement methods to promote quality, safety and social justice while reviewing a root cause scenario
4. Identify discrepancies between identified practice standards and current practice that may adversely impact patient outcomes.

Required Reading:  

• Marquis, B.L. & Huston, C.J. (2017). Leadership roles and management functions in nursing: theory and application. (9^th) Philadelphia, Wolters Kluwer Health. Pp. 614 – 616 Quality Control as a Process.
• https://www.health.state.mn.us/facilities/patientsafety/adverseevents/toolkit/

Optional Resources:

• https://www.youtube.com/watch?v=4bldoFN5a1g&feature=youtu.be
• https://www.thinkreliability.com/cause-mapping/what-is-root-cause-analysis/
• https://advisor-edu.lww.com/lna/search.do?s=21&m=f&q=sentinel%20events

Directions:

1. From the perspective of the Risk Manager, describe your specific health care event. What happened, who was involved?
2. Collect Data from your peers in your color group to help determine the root cause of the problem.
   1. What is the sequence of events? Use the RCA Sequence of Events tool. Complete these factual events in order to help make sense of the story leading up to, during and after the event. Include times as much as possible. Do not include opinions or interpretation of the events.
   2. Categorize possible causes and develop a Fish Bone Diagram (Ishikawa) including a minimum of one cause in each of the 6 fish bones on the diagram. Include all probable causes as appropriate.
   3. Individually, categorize possible causes for the problem/event. Fill out three 5 Why’s forms– Start with the problem on each form and then drill down on three separate forms of this tool to obtain three possible causes. (These 5 forms are part of the Appendix and will be turned in at the first due date for faculty feedback. See Step 11 prior to submission.)
3. In the body of the paper, explain the sequence of events/data collection. Describe your thought process while categorizing all possible causes on the Ishikawa Diagram. Focus on the 3 most probable causes for the problem. Refer to the Ishikawa diagram and your 5-Why’s. Why did they happen? Identify which conditions allowed the problem to occur.
4. Next, identify one of the three probable causes as the primary root cause and explain why you believe this is the primary root of the problem. Discuss how various roots could interplay to cause the problem.
5. Identify a national benchmark or standard of care that should be met in this scenario as it relates to the primary root cause.
6. Identify your expected outcome (SMART) that would help this color group meet the national benchmark or standard of care.
7. Cite your credible source to support the benchmark or standard of care and the goal/outcome.
8. Intervention – What should be done to prevent the problem from recurring? Formalize your realistic plans for implementing change that looks directly at the primary root cause you identified. Also discuss barriers to implementation.
   1. How will you implement this change?
   2. Include an expected timeline.
   3. What are the risks and/or barriers of implementing the change?
9. Evaluation – When would be a good time to evaluate whether or not your changes had the desired effect? Did your interventions achieve the desired outcome?
   1. What criteria will you measure so you know the Outcome was achieved?
   2. Who (title of person) is responsible for the final Outcome?
10. The conclusion should not have any new data presented.
    1. Summarize the problem, the missed benchmark, and your prevention plan.
    2. How does this incident apply to your probable future nursing practice? In other words, what did you learn?
11. References – Research a minimum of five sources (within the last 7 years); at least two must be peer reviewed health care journals.
12. Include the Sequence of Events, three separate 5 Why’s, and the Ishikawa diagram as appendices at the end of your paper. Refer to the data presented in each within your paper. g. See Appendix B which describes the … Also remember to follow APA formatting when deciding on the correct order in which to place the forms of the appendix.
13. Proof read your scholarly paper and compare to the rubric.