Question: Comment on their identified incident and description of their application of a root cause analysis.
Case Scenario:
Incident that occurred in my experience in healthcare institution as a student that was high risk.
The sentinel event was the serious illness of a hospital employee. She had a condition that required a particular medication that the hospital did not stock. She had no other options than to receive the medication from the pharmacy. When she began experiencing symptoms, the pharmacy could not provide medication that would help her.
How root cause analysis was utilized
The root cause analysis would be utilized in this incident to determine why the pharmacy did not have the available medication and how that would be prevented in the future. The root causes may have been human error, a new policy, or a lack of information or training. The root causes must be identified using a system analysis and the root cause analysis must be incorporated into a comprehensive program that will include procedures to correct the root causes and prevent the incident from occurring again. The root cause analysis must be well documented so that any future investigation can determine what happened, why it happened, and what could have been done to prevent the incident from happening again.
Comment on their identified incident and description of their application of a root cause analysis.