Root Cause Analysis

  The patient has been admitted to a 20-bed medical unit for treatment of acute diverticulitis. The provider has ordered Ultram (Tramadol hydrochloride) 50 mg p.o. every 6 hours prn pain. The patient is requesting a pain medication, as it has been 8 hours since his last dose. The nurse selects the individually wrapped medication from the patient's assigned medication drawer and scans the barcode to determine if it is the correct medication. The scanner is not working again. As she wants to administer the pain medication as soon as possible, she types in the Internal Entry Number (IEN) and the computer indicates the medication is Ultracet 37.5/325 mg but the package says Ultram 50 mg. The nurse calls the pharmacy and the pharmacist says there is only one number different between Ultram and Ultracet and, since the package says Ultram, to administer the medication because she must have typed in the wrong number. The nurse administers the medication, and within 30 minutes the patient shows signs of an allergic reaction. The nurse checks the record and determines the patient is allergic to acetaminophen. The patient is treated for the allergic reaction, and a medication incident form is completed. The nurse manager asks for a Root Cause Analysis (RCA) to be completed for the medication error.

Review the case scenario included in this week’s media resources, and examine the process flow chart, cause/effect diagram, and Pareto chart related to the case scenario.

In the scenario, 

The nurse manager and the director of pharmacy blame each other for the error. The facilitator (quality assurance person) asks everyone to avoid blaming and focus on applying the tools to analyze the data and get to the root cause of the error.

While all of these tools contribute, for this Assignment : Select one tool to analyze.


· Analyze the composition of the RCA team. 

· Explain what knowledge they can contribute to the RCA.

· Describe the collaboration in the case study that led to effective problem solving. Identify the evidence you observe in the scenario that demonstrates effective collaboration and the avoidance of blaming.

· Explain the team’s process in testing for and eliminating root causes that were not contributing.

· Select one of the performance improvement charts presented in the scenario and critique its effectiveness by explaining how it contributes to identifying the root cause and determining a solution to prevent repeat medication errors.

· Identify the contributing factors, and discuss how to prevent this kind of error from occurring in the future.

Support your response with references from the professional nursing literature. Your posts need to be written at the capstone level (see checklist)

NOTE; This should be a 5-paragraph (at least 550 words) response.

Be sure to use evidence from the readings and include in-text citations. Utilize essay-level writing practice and skills, including the use of transitional material and organizational frames. Avoid quotes; paraphrase to incorporate evidence into your own writing. A reference list is required. Use the most current evidence (usually ≤ 5 years old). (Refer to AWE Checklist, Capstone)

Spath, P. (2018). Introduction to healthcare quality management (3rd ed.). Chicago, IL: Health Administration Press.

  • Chapter 4, “Evaluating      Performance” (pp. 79-118)
  • Chapter 5, “Continuous      Improvement” (pp. 119-142)
  • Chapter 6, “Performance Improvement Tools”      (pp. 143-174)

Note: Although these chapters are previously assigned readings, please review them in preparation for this week’s material.

Yoder-Wise, P. S. (2019). Leading and managing in nursing (7th ed.). St. Louis, MO: Mosby.

  • Chapter 18, “Leading Change” (pp. 319-335)