Root Cause Analysis

Root Cause Analysis
Name
Institution Affiliation

Root Cause Analysis
Unlike computers and other programmable machines, human brains are prone to errors that result in severe damages. In the United States, medical errors resulted in the deaths of approximately 200,000 patients and a loss of $ 19.5 billion in 2008 (Andel et al. 39). Thus to minimize the risks of errors, researchers have developed analysis procedures which include the Root cause analysis structure. In healthcare, the root cause analysis uses the system approach to identify active as well as latent errors. In this case, the latent errors are hidden challenges that within a healthcare system that can cause severe damages while active errors are problems that arise between human interface and a complex machine system. The main factors that contribute to latent errors include the environment in which the patient is treated, leadership and organizational policies, the equipment being used in the healthcare facility as well as the characteristics of the patient. In this case, the root cause analysis presented describes a case of a 68-year old male admitted to the ICU for a surgical procedure was administered with Ketamine-Fentanyl rather than Heparin. The root cause analysis is presented in the form of a fishbone diagram.
Procedures
Medication Error
Distraction by family members and people within the hospital
Presence of family members during critical procedures
Lack of automated tools
Equipment Errors when operating the tools
Limited knowledge on how to use the equipment
Budget constraints
Patient with high demand care
Patient requiring specialized care
Lack of critical thinking skills
Human error that results from physical or mental distraction
Not following procedures and policies that guide medical operations
Lack of understanding of patient safety procedures
Working on tight schedule
Environment
Nurses
Patient
Equipment
Leadership
Procedures
Medication Error
Distraction by family members and people within the hospital
Presence of family members during critical procedures
Lack of automated tools
Equipment Errors when operating the tools
Limited knowledge on how to use the equipment
Budget constraints
Patient with high demand care
Patient requiring specialized care
Lack of critical thinking skills
Human error that results from physical or mental distraction
Not following procedures and policies that guide medical operations
Lack of understanding of patient safety procedures
Working on tight schedule
Environment
Nurses
Patient
Equipment
Leadership

Reference
Top of Form
Andel, C., Davidow, S. L., Hollander, M., & Moreno, D. A. (January 01, 2012). The economics of health care quality and medical errors. Journal of Health Care Finance, 39, 1, 39-50. Bottom of Form