Healthcare organizations accredited by the Joint Commission are required to conduct a root cause analysis (RCA) in response to any sentinel event, such as the one described in the scenario attached below. Once the cause is identified and a plan of action established, it is useful to conduct a failure mode and effects analysis (FMEA) to reduce the likelihood that a process would fail. As a member of the healthcare team in the hospital described in this scenario, you have been selected as a member of the team investigating the incident.
Use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.
- Explain the general purpose of conducting a root cause analysis (RCA).
- Explain each of the six steps used to conduct an RCA, as defined by IHI.
- Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome.
- Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome.
- Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan.
- Explain the general purpose of the failure mode and effects analysis (FMEA) process.
