Analyze the composition of the RCA team. Explain what knowledge they can contribute to the RCA.

Post each of the following:
•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)

Notes Initial Post: This should be a 3-paragraph (at least 250–350 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)
RCA Dramatization 1
Program Transcript
FEMALE SPEAKER: Medication errors are a plague. It involves a 20 bed medical treatment facility called Downtown Medical. Everyone at the facility had believed tat medication errors would decline there for two reasons. First, they started utilizing computerized physician order entry, or CPOE, in conjunction with online nursing documentation. NDMR. And also they began employing barcoded medication administration. But after four years of using these tools, there are still issues. Another medication error has occurred. In fact, there have been many constituting a significant pattern and trend. So an RCA team has been assembled. The team is comprised of me I’m the risk manager. Pamela Brown the staff nurse and Matthew White our pharm tech. We called our first meeting. And this is what happened. This medication error could have easily happened to anyone in our hospital. Our responsibility is to prevent it from happening again. This is the eighth medication error this month. We have a determine the cause of the error.

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I agree Linda. But if I could be direct for a second. I think if pharmacy got their act together we wouldn’t be having any of these problems.
You don’t want to start pointing fingers Pam.
Look we’ve all had our share of problems with this issue. And we are all on the hop for patient safety. We have to get at the root cause of what’s happening here. And that’s why I picked you for this team I need you to keep an open mind on this.
You are right. I’m sorry I made that comment, Matt.
No problem.
The thing is my nurses are always so stressed and understaffed. We hear complaints all the time about patient safety like it is all on us. The truth is the pharmacy at Downtown Medical really Is quite helpful. I mean that.
Thank you. What Pam said the same thing is true in the pharmacy. I’ve been a pharm tech here for 10 years and it feels like we are always understaffed. We never seem to have enough people. Maybe we should start by talking about that?
That’s a good idea, but I thought we’d look at the overall process first, from start to finish. Have either of you ever developed a process flow chart?
I’ve read about them. But I’ve never done one.
Well I was in on the last IT install. We did process flow charting for that.
So what I thought we’d do is use this first meeting to scope out how the process works. We’ll write it out. After that you should take it back to your departments and use it to conduct interviews with those who were involved with the actual medication error incident. And than we’ll use it on our next meeting. It that oK with you?
Works for me.
Yeah me too.

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OK Great. Then the next step will be to identify individuals we’ll want to interview to determine exactly what happened with the medication error. We’ll be constructing a cause effect diagram which is a qualitative tool done with some brainstorming after the interviews. And we’ll be analyzing last years medication errors as to primary cause. We’ll need weekly meeting and some ground rules to pull this off. Are you game?
The meeting got off to a bumpy start but once we focused on working together the RCA team embers were true to their word. They kept an open mind and agreed to meet on a regular basis to get the work done. In no time they helped me complete the process flow chart a cause and effect diagram and a complete analysis of a year’s worth of medication errors which were plotted on a Pareto chart. We were on our way.
RCA Dramatization 1
Additional Content Attribution
Footage: GettyLicense_113439900_h12.mov (could not get the video to download, hence wrote it out)

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