Analysis Of Root Cause Analysis

RAFT Task 2-ROOT CAUSE ANALYSIS-A Framework for a Root Cause Analysis and Action Plan in Response to a Sentinel Event
Introduction:

A root cause analysis for all sentinel events and near-misses should be conducted by every health care facility that is accredited by the Joint Commission. In near-miss scenarios, a root cause analysis is a very useful and important tool for the department, Senior Management, and the entire Hospital Board of Directors reviewing the information. The benefits of doing the analysis include a global bird’s eye view of the incident with all the details being asked and documented.
The Compliance/Accreditation Officers can facilitate system evaluation, analysis of need for corrective action, and tracking and…show more content…
Initially at registration, the parent or guardian information should have been asked and updated especially for a minor. This would have triggered the mother to respond about full custody issues that could be noted in the record. The next communication error occurred with the Pre-Op Nurse who wrote the mother’s cell phone in her personal notebook instead of the patient’s chart notes. She was the only nurse aware that the mother was leaving the hospital. Without her cell phone number in the chart notes, no other person was aware of the initial arrangements requested by the mother.
A. 2. Explain the roles of the personnel present during the sentinel event. Registrar-Katie Jessup: She is responsible for gathering all the pertinent patient demographics, such as name, insurance, contact information etc. when patients arrive to be seen at the hospital. She is also responsible for updating any pertinent information such as change of names, change of address and changes in the patient’s insurance. Currently there is no question that requires her to enter information about child custody…show more content…
3. Discuss the barriers that may impede effective interaction among the personnel present.

• Human Factors that were relevant to the outcome include the following: Communication Breakdowns. The mother-She should have made better plans for the other children involved. The parent of the child should always be present should anything happen and the parent needs to be contacted. The parent must take some of the blame in not calling the hospital once she was told the procedure would be only 45 minutes. She was gone for 2 ½ hours before she returned back to the hospital. The Doctor-Dr. Munoz stated that he has all the pertinent patient information but did not make sure that his office had communicated this information to the hospital admissions staff The Pre-OP Nurse-Ms. Doppke failed to properly document the mother’s cell phone number in the patient’s medical chart. Therefore, during the post-op care, the mother could have been reached and notified the procedure was finished. The Security Officer-Mr. Blakely was not notified of the Code Pink until about 25 minutes later. Even though he initially called up to announce the father’s arrival to see his daughter, he was not aware of the custody issue