This week, you analyze a case related to medication error, and you examine how root cause analysis is applied to prevent future error and formulate process improvement plans.

When patient safety is compromised, it is critical to get to the root of the issue in order to determine how to ensure patient safety and avoid risks in the future. Nurses can use analytical techniques to determine root causes related to various types of errors. Medication error is a typical error that can be subject to process improvement in general, and root cause analysis in particular. This process came out of NASA after the Space Shuttle Columbia disaster and has been adopted by the health care industry. This week, you analyze a case related to medication error, and you examine how root cause analysis is applied to prevent future error and formulate process improvement plans.

Learning Objectives

Students will:

  • Analyze the composition of a root cause analysis team      in relation to effective practice
  • Critique the effectiveness of the performance      improvement charts in identifying contributing factors
  • Apply findings from a root cause analysis to prevent      future errors
  • Apply a quality improvement process to an improvement      plan

Learning Resources 

Required Readings

Spath, P. (2013). Introduction to healthcare quality management (2nd ed.). Chicago, IL: Health Administration Press.

· Chapter 4, “Evaluating Performance” (pp. 73–110)

· Chapter 5, “Continuous Improvement” (pp. 111–130)

· Chapter 6, “Performance Improvement Tools” (pp. 131–162)

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

Yoder-Wise, P. S. (2015). Leading and managing in nursing (6th ed.). St. Louis, MO: Mosby.

· Chapter 17, “Leading Change” (pp. 305–320)

· Chapter 23, “Conflict: The Cutting Edge of Change” (pp. 431–447)

Required Media

Laureate Education (Producer). (2016a). Root cause analysis at Downtown Medical [Interactive file]. Baltimore, MD: Author.

Laureate Education (Producer). (2016b). RCA dramatization 1 [Video file]. Baltimore, MD: Author.

Note: The approximate length of this media piece is 4 minutes.

Case scenario involving medication error including pharmacy, physician, and nurse—interdepartmental collaboration.
Interactive media—students select options that generate chart based on choices
(Voiceover reads the document aloud—include a downloadable pdf).