Root Cause Analysis

Root Cause Analysis

Review the Root Cause Analysis Topic Materials to learn more about conducting a root cause analysis. Using the \”Root Cause Analysis Template,\” conduct a root cause analysis of the \”Root Cause Analysis Scenario.\” Post a description of the problem and a summary of your root cause analysis, including recommendations for proposed action to eliminate the problem from reoccurring. Select other peers\’ postings to peer review. Provide appropriate feedback.

HLT 605: Root Cause Analysis Template
Participants in the Root Cause Analysis (Indicate name and position)
• Insert name and position (Lead)
• Insert name and position (Lead)
• Insert name and position (Lead)

Root Cause Identification
In each of the areas below, indicate any factors that contributed to the delay in treatment:

Contributing Factors YES NO
If YES, what contributed to this factor being an issue? Is this a root cause of the event? If YES, is an action plan indicated?
Issues related to patient confidentiality?

Issues related to staff training or staff competency?

Nurses’ station location?
Lack of or misinterpretation of information?

Appropriate rules/policies/ procedures?

Personnel issues?
Supervisory issues?

Improvement Action Plan

Strategies for Improvement Measure(s) of Effectiveness Responsible Person(s)
Action item #1:
Action item #2:
Action item #3:
Action item #4:
Action item #5:

Root Cause Analysis Scenario

Use the scenario below to respond to Topic 4 DQ 2.

A town in the American Midwest has a population of approximately 20,000 people. The town is served by a local hospital that provides primary care and performs general surgeries. Many of the people in the town know each other.
A woman was admitted to the hospital for acute appendicitis and eventually had an appendectomy. While she was lying in bed awake one night, she overheard the nurses at the nurses’ station reviewing infectious control procedures and discussing a patient who was recently diagnosed as HIV positive. The other patients were sleeping so it was very quiet, and the voices were easily heard.
The patient\’s name was never mentioned, but based on the conversation, it was evident who he was by the way in which he was described, including comments about his job and his family. Based on the context of the conversation, the woman knew the patient was a teacher at the local middle school. He was a very well respected teacher and has served as a great mentor to his students.
When the woman was released, she proceeded to express her concern to neighbors, friends, and family, revealing the patient\’s name. She was nervous because her son was a student at the middle school and she did not want him to have any contact with the HIV-positive teacher. The knowledge became public and the teacher resigned from his position as a result of the embarrassment.

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