Application Quality Improvement Models Organizations Systems, Part I Analysis Required Resources Readings Course Text: Applying Quality Management HealthCare: A Systems Approach Review Chapter 9, "Improving Processes Implementing

Root cause analysis

According to Nicolini (2011)

the first step in RCA is identifying the incident to be analyzed. This step requires for the problem or incident to be clearly defined and identified. Identifying the problem will assist in determining what caused the incident and how the incident occurred. In the case study, the mother requested for pain medication, and this was within her right. The nurse performed the request, and it was approved by the pharmacist, but the incident occurred when the nurse did not check the IV line correctly. The nurse confused the infants IV line with the mothers, which resulted in the infant been administered with Morphine. This should be an indicator, and it should be recorded as a fact....
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