Sample Case Study On S6 Joint Commission RCA Tool ()

The Joint Commission on Accreditation of Healthcare Organizations requires the root cause analyses in order to extract detailed information. Root cause analyses aid the need for corrective action, system evaluation and trending and tracking. Trending enables the managers to find out the number of times a particular error occurred and the frequency in which a unit of the hospital is involved. The information obtained provides hints to the main problem.
In this case, the relevant human factors present are a patient from surgery who required medical attention and no one was answering the switchboard. The IV was also beeping as the patient was struggling to get someone to come to the patient’s aid, but no one attended to the patient until later. The equipment performance is an addition also affected the outcome the call bell was not functioning.
The difficulty in determining proximate causes and the underlying causes in this case is because the error reported has not been trending. The malfunction of the call bell was due to electrical fault and was not by default. The nurses did replace the call bell, and that showed initiative. The reason for no one answering the switchboard could have been that the nurses were making rounds in the wards. In this case, it is difficult to conclude that there was negligence on the nurse’s part.
However, by using the root analyses the causal factors are identified by conducted labor-intensive investigations. The root cause analysis in the process can enhance teamwork. It can also identify changes required and facilitate a culture of patient safety. The RCA is conducted on various levels of complexity and depth. It is important to note that the RCA is conducted to find out who committed the error rather as a means to determine how to improve the system of operation.