Root cause analysis (RCA) is a standard tool used to help health care organizations learn from errors, particularly those that result in harm. RCA is applied to address three key questions about a particular situation.

•What happened?

•Why did it happen?

•What can be done to prevent it from happening again?

To prepare for and complete this Discussion:

•Examine the "Appendix: Root Cause Analysis Tool," Foundations in Patient Safety for Health Professionals. This tool will serve as a foundation for the Discussion. If you were conducting a Root Cause Analysis in a health care organization with the actual individuals involved, you would be able to use this tool more fully. For this assignment, you will use this tool as a jumping off point for discussion and analysis.

•Discuss each element of the Root Cause Analysis Tool in relation to your selected scenario. Answer the following questions for your paper:

?What information from your selected scenario would help you to "fill in" each row or column of the Root Cause Analysis Tool? Identify as much information as you can for each row/column of the tool. For instance, what indicators from the scenario you have chosen should be included in response to "What are the details of the event (brief description)?"

?If certain information is not provided in your selected scenario, how would you, as a team, proceed to gather data?

?Who should participate in this analysis? Which roles or which specific individuals should be invited to participate?

?What questions or considerations (beyond what is included in the tool) would help to guide your investigation?

•Summarize key insights that you gained about your selected scenario, this type of sentinel event, and use of the Root Cause Analysis tool.