A root cause analysis involves a structured investigation whose objective is the identification of a problem’s true cause, as well as the necessary actions for its elimination (De Silvestro et al, 2013). In this case, a patient suffered a hemolytic transfusion reaction after…
The problem and event are to be defined and described factually, which will include quantitative and qualitative properties/attributes of the harmful outcomes. In this case, this will include a specification of the timing, location, magnitude, and nature of the event. Another component that will be used in this particular RCA will be the collection of data to ascertain that the problem does exist, the length of time that the problem has existed, and the impact the problem has portended on the patient (De Silvestro et al, 2013). The hemolytic transfusion reaction will be analyzed fully prior to examining the contributing factors, which will involve assembling experts from several disciplines that comprehend the situation.
A third component of the RCA will involve the identification of possible causative factors, in which the RCA will seek to investigate the sequence of events leading up to the hemolytic transfusion reaction, the conditions that allowed the reaction to happen, and other problems associated with occurrence of the reaction (De Silvestro et al, 2013). As many causal factors are to be identified in this component as possible using various tools. These are appreciation to determine every possible consequences of a specific factor, using the 5 why’s to get to the reaction’s root, breaking down the problem into smaller and more detailed portions, and using cause and effect diagrams. Finally, the RCA will also use the recommendation component by seeking to provide solutions about how to prevent another occurrence of a similar reaction and the prevalent risks in implementing the provide solutions (De Silvestro et al, 2013). This component will involve an analysis of the cause and effect process, as well as identification of changes required for the department. Tools that can be used here include the Failure Mode and Effects Analysis, Impact Analysis, and Continuous Improvement Analysis.
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