Part 1
Assignment Content
Risk management includes a funding mechanism that stimulates investment in loss prevention
and loss control measures to reduce the cost of risk. Funding may be obtained through a
percentage of workers’ compensation base accrual rates. Investing in loss prevention reduces
claim frequency, which has a positive effect on severity and overall claim exposure. An
appropriate tracking system documents losses or exposure prior to initiating the new program
and, after a selected time, documents the effect of the program on losses or exposure.
Imagine this scenario: You’re writing a blog post for a blog site whose readers are heads of risk
management departments.
Select 1 loss prevention initiative from your own experience or from peer-reviewed scholarly
sources.
Write a 500- to 700-word blog post that analyzes your selected loss prevention initiative. In
your blog post:
o Summarize the background, goals, and needs of your selected loss prevention initiative.
o Identify the loss prevention initiative’s:
o Primary and secondary funding sources
o Funding constraints for each source
o Describe a plan to structure these funding sources to meet the initiative’s goals.
o Specify the potential internal ramifications that may arise when implementing the loss
prevention initiative and your plan for managing the ramifications.
Include relevant visuals and external website links to support the initiative.
Cite the references and visuals you used to support your assignment.
Format your citations according to APA guidelines.
Part 2
Assignment Content
In this course, you will engage your thoughts and abilities, and you will position yourself as a
scholar, a practitioner, and a leader to advance your knowledge and personal academic agenda.
Consider saving this assignment for future reference, because it serves as a critical program
growth reflection.
Create a reflective and applied statement in which you:
o Describe how the material from Wks 1–4 has affected your thought processes,
development, and professional disposition.
o Reflect on your personal learning process (e.g., challenges, moments of discovery, life
experiences, and interactions).
o
Include questions for the course facilitator regarding material that may still be unclear.
Use this assignment as an opportunity throughout the course and the program to document
your development as a scholar, practitioner, and leader, and to reflect critically on the changes
that occur during this process.
Format your citations according to APA guidelines.
Running header: Framework for Conducting a Root Cause Analysis
Framework for Conducting a Root Cause Analysis
Samantha Powell
University of Phoenix
DHA/715
Mary Jo Brinkman
April 17, 2023
1
Framework for Conducting a Root Cause Analysis
2
Root cause analysis
A root cause analysis refers to a set of processes intended to discover the cause of a
problem for immediate intervention. The technique assumes that it is more effective to identify
underlying issues systematically and mitigate and solve them rather than treating the symptoms
and consequential problems (Rodziewicz & Hipskind, 2020). Root cause analysis can use a wide
range of methodologies, techniques, and principles to identify the root cause of a problem
helping us to look beyond the superficial cause and effect and identify the factors that caused the
situation in the first place.
Event Description
Date: 2022
Day of the Week: N/A
Time: N/A
Detailed event description
The “A Never Event” case study identifies an outbreak of Hepatitis in 2002 in Fremont, Nebraska.
May of the same year marks Hepatitis C awareness month, and the duo of Everlyn McKnight and
Travis Bennington attempt to spread awareness so that Hepatitis epidemics don’t happen again
(McKnight & Bennington, 2008). They report that in 2002, a Fremont-based cancer center had an
outbreak of Hepatitis C, which infected 99 patients. McKnight was battling breast cancer then and
used to get treated at the Fremont-based center. She noted that patient Zero entered the clinic for
cancer treatment, and her blood contaminated the saline bag. The blood allowed them to trace the
Hepatitis C infection to the first person. Travis Bennington co-wrote the book “A Never Event” in
2002 to raise Hepatitis C awareness in their community (McKnight & Bennington, 2008). Travis
also represented 19 patients to raise awareness about the disease.
Framework for Conducting a Root Cause Analysis
3
Diagnosis
An anti-HCV test is required to ascertain whether a person has suffered from Hepatitis C before.
The test looks for antibodies in the blood emitted as proteins into the blood after a person
contracts Hepatitis C.
Medications
Autopsy results
Injecting drug users are linked to increase in virus infections. A country wide study showed several
infection in the postmortem blood of dead drug users linking them to the serological investigation
Patients need to reduce the effects of Hepatitis B on the liver by taking direct-acting antiviral
Medical
and tenofovir,
psychiatricgrazoprevir,
history
tablets like
and paritaprevir.
The
community had a previous outbreak of Hepatitis C in 1999. All affected patients were
.
diagnosed with a form of cancer
Analysis
Prompts
Analysis Finding
Root cause Types
Questions
1
Casual Factors/Root
Cause Details
What was the
List the relevant
1. The MD was the last
1. The doctor was not
1. The doctor had a
intended
process steps as
person to be seen y the
thinking about the
printed copy of his
process flow?
defined by the
six Hepatitis C patients
case specifics; instead,
schedule. He should have
policy,
2. After the last
he looked at the larger
monitored the cases he
procedure,
Hepatitis C procedure,
picture. He knew his
was to operate on and
protocol, or
one patient was
schedule and patients
marked them off once
guidelines in
unhappy with the
but failed to pay
complete
effect at the time
Framework for Conducting a Root Cause Analysis
4
of the event. You
anesthesia injection she
attention to small
2. The same operations
may need to
received
details
were scheduled for the
include multiple
3. MD comforted the
2. There was no
same day in the coming
processes.
patient
control over
week. For example,
Examples of
4. MD’s translation
scheduling during the
Hepatitis C patients were
defined process
intervention greatly
patient’s procedure
released on Monday, and
steps may
aided the patient’s pre-
3. It was appropriate
their finger trigger
include, but are
operation
for the MD to comfort
procedure was scheduled
not limited to:
5. The medical center
the woman. However,
for Tuesday the next
• Site
has no translators on
he should have taken
week.
verification
hand
at least ten minutes to
3. MD to take personal
protocol
6. The resident nurse
get his composure
days to regain composure
• Instrument,
marked the patient’s
before handling
after the incident.
sponge, sharps
arm according to the
another case.
4. The hospital needs to
4. The hospital should
prove Spanish-speaking
count procedures institution’s policies. It
• Patient
shows no evidence of
have had a Spanish
employees and
identification
an incision
interpreter for the
translators for patients.
protocol
7. The day had
woman instead of
5. The hospital should
• Assessment
increased tension in the
relying on the MD.
encourage employees to
facility caused by
The RN should have
offer their lingual talents
supply delays
used the interpreter in
as translators. It will help
8. The hospital
her pre-op procedures.
reduce tension and
(pain, suicide
risk, physical,
and
rearranged the
Framework for Conducting a Root Cause Analysis
5
psychological)
operating room for the
5. The main question
misunderstandings like
procedures
operation. OR staff and
to ask is:
the one witnessed.
• Fall risk/fall
equipment were
Did the hospital call a
6. The MD should make
prevention
relocated in the
translator for the
proper incision marks. A
guidelines Note:
process.
woman?
second employee should
The process
9. The change caused
Was the available
verify the mark’s location
steps as they
the operation to delay
interpreter busy with
to prevent such
occurred in the
10. Due to the changes,
another case?
incidences. The hospital
event will be
the RN that marked the
If so, did the hospital
should maintain a
entered in the
woman’s arm could not
have another
minimum of 16 RNs each
next question.
attend the procedure
interpreter or Spanish-
day. Their shifts should
11. MD was also absent speaking staff?
change depending on the
attending to other
6. Why didn’t the MD
operating schedule
patients.
mark the right arm for
7. The hospital should
12. MD warned that the incision after it came
enact measures to ensure
injection of local
the operating room is
off? Did the patient
anesthesia disturbed the approve the
ready for changes. The
patient. The patient
procedure?
team should ensure OR
appeared upset and
7. Why did the
equipment is functioning
anxious. He sowed
hospital experience
appropriately
concern for the patient
increase stress during
8. New employees in the
when he went to visit
the operation? Were
OR should be informed
her.
of the patient and their
Framework for Conducting a Root Cause Analysis
6
12. The doctor stated,
there enough people
situation for them to act
“The next operation
for the procedure?
correctly
could be the greatest
8. Was the supply
9. Hospital should
Hepatitis C procedure
delay due to poor
implement reports and
he has ever done.”
patient scheduling?
hand-offs during the
13. The operating
9. Equipment faults
transition from one shift
doctor lacked a
and supply delays may
to another. This will
tourniquet
have caused the
improve coordination.
14. Before the
procedure
10. MD must take some
procedure, the doctor
rescheduling.
time off to reassess his
cleaned his hands with
10. The case shows
priorities. During the
alcohol, iodine, and
the RN did not
time out, he can attend to
soap per hospital
correctly hand over
former patients.
practices. The hand-
her role to the new
11. MD needs a new
washing method caused nurse. Why was the
surgical calendar to keep
the site marker to be
RN not present during
track of his operations
removed.
the operation?
during the day.
15. Since the initial RN
Did she have other
12. RN should use a
could not attend, a new
cases?
visible marker even after
nurse was assigned to
11. The MD visited
surgical preparation. The
the patient (McKnight
the patient since she
solution should be
& Bennington, 2008).
complained; it was the
resistant to alcohol.
right thing to do. The
Framework for Conducting a Root Cause Analysis
7
16. The new nurse used
doctor should have
13. Before taking on a
the carpal-tunnel
recovered his
new case, the staff should
release procedure
composure after
take time out to prevent
instead of the normal
interacting with the
incidents
trigger finger procedure patient
14. The time out should
12. Was the soap and
also apply to patients to
povidone-iodine not
help them calm down
sufficient to clean the
15. If staff changes are
location? Was using
needed mid-procedure,
alcohol necessary?
the outgoing RN must
The staff used the
hand-off the case to the
correct cleaning
incoming nurse
procedures; however,
16. Doctors should have
the use of alcohol
dictations after each
should be evaluated.
procedure
13. Why did the entire
OR team shift rooms
mid-procedure?
2
Were there any
Explain in detail
The hospital had no
1. The hospital has no
1. The patient should
steps in the
any deviation
interpreter
translator, which
have been given a phone
process that
from the
The RN marked the
makes the meeting’s
or translator if their next
did not occur
intended
incision spot without
purpose unclear
of kin was not present
as intended?
processes listed
assistance or
Framework for Conducting a Root Cause Analysis
8
in Analysis
supervision from other
2. Why didn’t the MD
2. The MD should have
Question #1
employees (McKnight
sign it if the patient’s
marked the incision area
above
& Bennington, 2008).
operation was chosen
with another person.
Non-English patients
based on the hospital’s
When the mark
should be assigned a
policy?
dissipated, the doctor
native to answer their
3. Why didn’t the
should have confirmed
questions
woman have a next of
the incision site before
There was a clear lack
kind or friend who
the procedure (McKnight
of communication
could translate during
& Bennington, 2008).
between the RN and
the operation?
3. One or two family
OR team.
4. Before starting the
members should be in the
There was no check-out procedure, why was
pre-op procedure. The
procedure for staff
the OR team still
hospital should obtain
The room might have
there? Was there a
informed consent and
been understocked,
scheduling error?
verify the process before
leading to rising
Before a patient can
it starts.
tensions.
begin treatment, the
4. The hospital should
The alcohol mixture
room should have all
implement a check-off
removed the initial
the equipment needed
policy where the leaving
mark
for the procedure.
staff informs those
The OR crew changed
coming about the patient,
mid-operation
case, and what is
Framework for Conducting a Root Cause Analysis
9
required (Pereira-Lima et
al., 2019).
3
What human
Discuss staff-
The doctor was
1. Although the MD
1. During the day, the
factors were
related human
thinking of big
sticks to his schedule,
MD should check his
relevant to the
performance
procedures as opposed
he must view patient
schedule and make sure
outcome?
factors that
to minor ones. He
cases individually
everything goes right. He
contributed to
states, “Today I will
2. The case took
should mark off
the event.
have the greatest
longer than expected,
completed procedures.
Examples may
Hepatitis C operation.”
leading to increased
2. MD must take
include, but are
Worn out by the
tension in the OR and
personal days to relieve
not limited to:
procedure and
irritation of both the
stress and decompress
• Boredom
subsequent patient
doctor and nurses
3. In case of delays, the
• Failure to
interactions, he was
conducting to the
team should take time to
follow
still focused on the
nurse using shortcuts.
assess the situation. The
established
previous patient instead
3. When things went
process should go as
policies/procedu
of the current one.
wrong, the staff should planned without taking
res Fatigue
Other factors that
have owned up to the
any shortcuts
• Inability to
compromised the
mistake. They should
4. The hospital should
focus on a task
operation were
not blame themselves
assign someone to call
• Inattentional
equipment delays and
or their workmates, or
the OR before the
failure to prepare the
they may cause
procedure and ensure
OR before the
another medical error.
everything is needed. The
blindness/confir
mation bias
procedure.
MD should make the
Framework for Conducting a Root Cause Analysis
10
• Personal
Evident communication
incision with the
problems
breakdown saw
assistance of another
• Lack of
between employees.
practitioner
complex critical
The incoming nurse
5. Before starting the
thinking skills
chooses the wrong
surgery, the team should
• Rushing to
incision site leading to
have a 5-minute break to
complete the
the patient’s discomfort.
review the surgery ahead
task
Language barriers
and their steps.
• Substance
between the doctor and
abuse
• Trust
4
patient worsened the
situation
How did the
Consider all
1. Defective oximeter
equipment
medical
sensors
performance
equipment and
2. Defective vital
affect the
devices used
monitoring system
during patient
3. Gauzes, clamps, and
care, including
curtains missing from
automated
the OR
external
defibrillator
devices, crash
carts, suction,
Yes
Yes
Framework for Conducting a Root Cause Analysis
11
oxygen,
instruments,
monitors,
infusion
equipment, etc.
In your
discussion,
provide
information on
the following, as
applicable:
• Descriptions of
biomedical
checks
• Availability
and condition of
the equipment
• Descriptions of
equipment with
multiple or
removable
pieces
Framework for Conducting a Root Cause Analysis
12
• Location of
equipment and
its accessibility
to staff and
patients
• Staff
knowledge of or
education on
equipment,
including
applicable
5
What
What
The lack of curtains
controllable
environmental
could cause a lighting
environmental
factors within
issue that disorients the
factors affected the
the outcome?
organization’s
control affected
the outcome?
Examples may
include, but are
not limited to:
doctor.
Yes
Yes
Framework for Conducting a Root Cause Analysis
13
• Overhead
paging that
cannot be heard
in physician
offices
• Safety or
security risks
• Risks
involving
activities of
visitors
• Lighting or
space issues The
response to this
question may be
addressed more
globally in
Question #17.
This response
should be
specific to this
event
Framework for Conducting a Root Cause Analysis
14
6
What
Identify any
uncontrollably
factors the health
Not identified
No
No
Yes
Yes
external factors care organization
influenced the
cannot change
outcome?
that contributed
to a breakdown
in the internal
process, for
example, natural
disasters.
7
Were there any
List any other
1. Lack of appropriate
other factors
factors not yet
equipment
that directly
discussed
2. Lack of equipment
influenced this
maintenance
outcome?
3. Oblivious to the
patient’s pain
4. Communication
barriers between shifts
8
What are the
List all other
1. Radiology lab in unit
other areas in
regions in which
2. Oncology
the health care
the potential
department
organization
exists for similar
3. Operating rooms
Framework for Conducting a Root Cause Analysis
15
where this
circumstances.
could happen?
For example: •
Inpatient
surgery/outpatie
nt surgery •
Inpatient
psychiatric
care/outpatient
psychiatric care
• Identification
of other areas
within the
organization that
can impact
patient safety
similarly. This
information will
help drive the
scope of your
action plan
9
Was staff
Include
1. Staff were competent Yes
properly
information on
in the procedure
Yes
Framework for Conducting a Root Cause Analysis
16
qualified and
the following for
2. Lack of an adequate
currently
all staff and
number of employees
competent for
providers
in the OR
their
involved in the
3. Staff ineffectiveness
responsibilities
event. Comment
4. Lack of proper
?
on the processes
training in patient care
in place to
ensure staff is
competent and
qualified.
Examples may
include but are
not limited to:
•
Orientation/train
ing
• Competency
assessment
(What
competencies
does the team
have, and how
Framework for Conducting a Root Cause Analysis
17
do you evaluate
them?)
Provider and
staff scope of
practice
concerns
• Whether the
provider was
credentialed and
privileged for
the care and
services they
rendered
• The
credentialing and
privileging
policy and
procedures
• Provider and
staff
performance
issues
Framework for Conducting a Root Cause Analysis
18
10 How did actual
Include ideal and 1. Ideally, the staff
staffing
actual staffing
should monitor the
compare with
ratios and the
patient after every five
the ideal level?
unit census at the minutes. McKnight was
time of the
not watching every five
event. Note any
minutes due to a staff
unusual
shortage
circumstances
2. Pneumothorax is a
that occurred at
deadly condition that
this time. What
the staff mismanaged
process
(So et al., 2019). It
determines the
shows the staff were
care area’s
incompetent
staffing ratio,
3. There should be at
experience level,
least one worker for
and skill mix?
two patients to prevent
Yes
Yes
Yes
Yes
understaffing and
increase efficiency
11 What is the
Include
1. Next of kin should
plan for
information on
be able to consent
dealing? With
what the
before procedures
healthcare
(Mustafayev & Torres,
Framework for Conducting a Root Cause Analysis
19
staffing
organization
2022). This can be
contingencies?
does during a
either physically or
staffing crisis,
electronically.
such as call-ins,
Personnel performing
bad weather, or
the procedure should
increased patient
input their names or
acuity. Describe
initials on check-out
the healthcare
sheets, medical reports,
organization’s
and other documents to
use of alternative enhance accountability.
staffing.
Examples may
include, but are
not limited to:
• Agency nurses
• Cross training
• Float pool
• Mandatory
overtime
• PRN pool
12 Were such
If the alternative
contingencies a staff was used,
Yes
Yes
Yes
Framework for Conducting a Root Cause Analysis
20
factor in this
describe their
event?
orientation to the
area, verification
of competency,
and
environmental
familiarity.
13 Did staff
Describe
The staff failed to meet
performance
whether staff
the expectations of the
during the
performed as
procedure. They also
event meet
expected within
failed to meet the
expectations?
or outside of the
hospital’s policies.
processes. To
•
The staff neglected
what extent was
McKnight, with her
leadership aware
transport to SSU
of any
being delayed
performance
•
deviations at the
time? What
Poor patient
monitoring
•
Little to no records
proactive
are kept between
surveillance
shifts
processes exist
No
No
Framework for Conducting a Root Cause Analysis
21
for leadership to
•
Lack of reliable
identify
information before
variations from
procedures
expected
operations?
Include
omissions in
critical thinking
and performance
variance(s) from
defined policy,
procedure,
protocol, and
guidelines in
effect.
14 To what degree Discuss whether
1. Staff didn’t have
was all the
patient
access to the patient’s
necessary
assessments
evaluation
information
were completed,
2. No communication
available when
shared, and
to the management
needed?
accessed by
until the following day
treatment team
No
No
Framework for Conducting a Root Cause Analysis
22
Accurate?
members,
3. The error caused
Complete?
including
harm to the patient, and
Unambiguous?
providers,
her health deteriorated
according to the
after the procedure
organizational
4. Patients should
processes.
maintain the same
Identify the
practitioners and nurses
information
before and after
systems used
procedures to minimize
during patient
errors
care. Discuss to
what extent the
available patient
information
(e.g., radiology
studies, lab
results, or
medical records)
was clear and
sufficient to
adequately
summarize the
Framework for Conducting a Root Cause Analysis
23
patient’s
condition,
treatment, and
response to
treatment.
Describe staff
utilization and
adequacy of
policy,
procedure,
protocol, and
guidelines
specific to the
patient care
provided.
15 To what degree Analysis of
is
1. Lack of
factors related to
communication
communication communication
between shifts
among
should include
2. Lack of
participants
evaluation of
communication before
adequate?
verbal, written,
procedures
and electronic
No
No
Framework for Conducting a Root Cause Analysis
24
communication
3. McKnight’s
or the lack
transportation was
thereof.
rushed
Consider the
4. Language barrier
following in
between practitioners
your response, as and the patient
appropriate: •
5. No consent or
The timing of
communication to next
transmission of
of kin
key information
6. Lack of a family
•
member before starting
Misunderstandin
a life-threatening
gs related to
surgery
language/cultural
barriers,
abbreviations,
terminology, etc.
• Proper
completion of
internal and
external hand-off
communication
Framework for Conducting a Root Cause Analysis
25
Involvement of
patient, family,
and significant
other
16 Was this the
Consider
No, the OR didn’t have
appropriate
processes that
the right physical
physical
proactively
environment for the
environment
manage the
procedure because:
for the
patient care
1. No equipment
processes
environment.
testing was done before
being carried
This response
the surgery. The
out?
may correlate to
audibility of the life
Question #6 on a
support was not tested
more global
2. No incision point
scale. What
examination was done
evaluation tool
3. No correspondence
or method is in
to the management
place to evaluate
until the next day
process needs
and mitigate
physical and
patient care
N/A
N/A
Framework for Conducting a Root Cause Analysis
26
environmental
risks? How are
these process
markets
addressed
organizationwide?
17 What systems
Identify
No processes were
are in place to
environmental
implemented to
identify
risk assessments.
identify and classify
environmental
Does the current
environmental risks
risks?
environment
meet codes,
specifications,
and regulations?
Does the staff
know how to
report ecological
risks? Was there
an
environmental
risk involved if it
No
No
Framework for Conducting a Root Cause Analysis
27
was not
previously
identified?
18 What
Describe
1. No emergency
emergency and
variances in the
procedures
failure-mode
expected process
responses have
due to an actual
been planned
emergency or
and tested?
failure mode
response to the
event. Related to
this event, what
safety
evaluations and
drills have been
conducted and at
what frequency
(e.g., mock code
blue, rapid
response,
behavioral
emergencies,
N/A
N/A
Framework for Conducting a Root Cause Analysis
28
patient
abduction, or
elopement)?
Emergency
responses may
include but are
not limited to: •
Fire • External
disaster • Mass
casualty, and
Medical
emergencies.
Failure mode
responses may
consist of but are
not limited to:
• Computer
downtime
• Diversion
planning
• Facility
Construction
Framework for Conducting a Root Cause Analysis
29
• Power loss
• Utility issues
19 How does the
How does the
1. The hospital should
organization’s
overall culture
diversify its staff
culture support
encourage?
culture to create an all-
risk reduction?
Change,
inclusive workforce.
suggestions, and
Having employees
warnings from
from other races could
staff regarding
have mitigated the
risky situations
language barrier.
or problem
2. Hospitals need to
areas?
include the next of kin
• How does
in intricate procedures
leadership
like pre-op evaluation
demonstrate the
3. Staff sensitization
organization’s
programs on providing
culture and
care should be
safety values?
implemented
• How does the
organization
measure culture
and safety?
YES
YES
Framework for Conducting a Root Cause Analysis
30
• How does
leadership
address
disruptive
behavior?
• How does
leadership
establish
methods to
identify areas of
risk or access
employee
suggestions for
change?
• How are
changes
implemented?
20 What are the
barriers to
Describe specific Lack of communication YES
barriers to
among staff and
communication effective
between shifts
of potential
communication
Lack of cooperation
risk factors?
among
among team members
YES
Framework for Conducting a Root Cause Analysis
31
caregivers
identified by the
organization—
for example,
residual
intimidation or
reluctance to
report co-worker
activity. Identify
the measures to
break down
barriers (for
instance, using
SBAR). If there
are no barriers to
communication,
discuss how this
is known
21 How does
Does leadership
Managers oversee the
leadership
demonstrate
conduct and
address the
accountability
development of their
continuum of
for
facilities. They monitor
YES
YES
Framework for Conducting a Root Cause Analysis
32
patient safety
implementing
employee performance
events,
measures to
and ensure continual
including close
reduce the risk
talent development
calls, adverse
of patient harm?
through training.
events, and
Has the
unsafe,
administration
hazardous
provided for
conditions?
required
resources or
training? Does
leadership
communicate
corrective
actions
stemming from
any analysis
following
reported threats?
How can
Please describe
orientation and
how the staff’s
in-service
orientation and
ongoing
N/A
N/A
Framework for Conducting a Root Cause Analysis
33
training be
education needs
improved?
are evaluated
and discuss their
relevance to the
event.
(Competencies,
critical thinking
skills, use of
simulation labs,
evidence-based
practice)
23 Was available
Describe
The use of Thoracic x-
technology
variances in the
ray and tomography
used as
expected process
scan
intended?
due to education,
training,
competency, the
impact of human
factors, the
functionality of
equipment, and
so on:
NO
NO
Framework for Conducting a Root Cause Analysis
34
• Was the
technology
designed to?
Minimize use
errors or easy-tocatch mistakes?
• Did the
technology work
well with the
workflow and
environment?
• Was the
technology used
outside of its
specifications?
24 How might
Describe any
The center should
technology be
future for
adopt technology to
introduced or
implementation
identify and document
redesigned to
or redesign.
incision points.
reduce risks in
Describe the
The hospital should use
the future?
ideal technology
technology to create a
system that can
centralized information
Yes
Yes
Framework for Conducting a Root Cause Analysis
35
help mitigate
system that shows the
potential adverse
patient’s medical
events in the
history, current case,
future.
and the follow-up
procedures needed
(Pereira-Lima et al.,
2019).
Corrective actions
Root Cause Causal
Types
Corrective Action
Action Strength
factors
Measure of
Sample size
Success
1. Policy
Ensure efficiency and
Medical
Education
adherence to evidence-based
professionals
Entire workforce
medical practice.
Improve clinical staff skills
2. Create
Create easy and quick
Frequency and
Management
communication
communication lines between
speed of
lines with
employees and directors
communication
3. Improve OR
Purchase better equipment
Frequency of
Lab and general
technology
Train technicians on device
breakdowns
technicians
management
maintenance and repair
Framework for Conducting a Root Cause Analysis
36
4. Improve staff
Improve communication
Work efficiency
Entire workforce
communication
among employees
5. Fast supply
Purchase of new transportation
Waiting time
Finance
chain
and medical equipment
before delivery
Source suppliers from
domestic industries
6. Improve
Purchase new technology to
Number of
patient diagnosis
support X-rays and CT scan
accurate
tests
diagnoses
Purchase
7. Record keeping Implement a record-keeping
Increase access
IT and clerical
system in light of McKnight’s
to information
department
case (McKnight &
among staff
Bennington, 2008).
Framework for Conducting a Root Cause Analysis
37
References
McKnight, E. V., & Bennington, T. T. (2008). A never event: Exposing the largest outbreak of
hepatitis C in American healthcare history. Arbor Books.
Mustafayev, K., & Torres, H. (2022). Hepatitis B and hepatitis C virus reactivation in cancer
patients receiving novel anticancer therapies. Clinical Microbiology and Infection.
Pereira-Lima, K., Mata, D. A., Loureiro, S. R., Crippa, J. A., Bolsoni, L. M., & Sen, S. (2019).
Association between physician depressive symptoms and medical errors: a systematic
review and meta-analysis. JAMA network open, 2(11), e1916097-e1916097.
Rodziewicz, T. L., & Hipskind, J. E. (2020). Medical error prevention. StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing.
So, H. Y., Chen, P. P., Wong, G. K. C., & Chan, T. T. N. (2019). Simulation in medical
education. Journal of the Royal College of Physicians of Edinburgh, 49(1), 52-57.
Running header: PCA Activities Executive Summary
PCA Activities Executive Summary
Samantha Powell
University of Phoenix
DHA/715
Mary Jo Brinkman
April 10, 2023
1
PCA Activities Executive Summary
2
Executive Summary
My current healthcare organization conducts peer customer assessment rounds six times a
month, with the leadership visiting at-least two units in each round to establish a face-to-face
connection with staff and patients. However, recently the organization has exponentially
increased its number of healthcare institutions. The increase in scope has lowered the number of
peer customer assessment rounds made per unit, and the practice is becoming too large to be
deemed successful. Due to these limitations, the organization’s management is looking for
alternative approaches that achieve the organization’s goals. Some proposed alternatives include
staff mentoring, quality assessment audits, and conducting patient feedback sessions. Each of
these alternatives allows the HCO to interact with its patients and staff to discuss the patient’s
experience and improve their health triage and other systems.
Patient feedback sessions will allow the management to interact with multiple patients
from different organizational units. The practice will involve conducting personal interviews or
focus groups to review their healthcare experience and identify any areas of dissatisfaction
(Gishu, Weldetsadik, & Tekleab, 2019). Collecting patient feedback allows the organization to
interact directly with patients and better understand the patient’s personalized health experience.
It’s essential to evaluate patient satisfaction and identify areas of weakness to improve the
organization’s service provision and healthcare outcomes. Ideally, these management-patient
interactions should occur in a conducive atmosphere without judgment toward the patient or
employee. The practice will allow the organization to review its services from the patient’s
perspective and make it easier to fulfill patients’ requirements.
Staff monitoring will allow the HCO to review its current system and document how the
staff delivers patient-centered care to its patients. It enables the organization to build trust among
PCA Activities Executive Summary
3
its employees and further the staff’s skills through training and mentoring. The practice will also
encourage employees to improve their service provision and openly identify areas they feel need
improvement. Quality audits give the HCO a measurable mechanism of ensuring their units
provide the best possible healthcare. It can hire internal auditors or an external audit firm to carry
out the assessment, and audits can occur three times a year, allowing the management to review
its service provision each quarter (Naeini et al., 2019). Findings from these audits will enable the
management to identify areas of weakness and quickly resolve them.
PCA Activities Executive Summary
References
Gishu, T., Weldetsadik, A. Y., & Tekleab, A. M. (2019). Patients’ perception of quality of
nursing care; a tertiary center experience from Ethiopia. BMC Nursing, 18(1), 1-6.
Naeini, E. K., Azimi, I., Rahmani, A. M., Liljeberg, P., & Dutt, N. (2019). A real-time PPG
quality assessment approach for healthcare Internet-of-Things. Procedia Computer
Science, 151, 551-558.
4
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