Write a 750-1,000 word paper that explains the root cause analysis process that the health care organization would use and
perform a root cause analysis. Quality improvement requires multiple perspectives to identify root causes and develop optimal
solutions for success.
Prior to creating the root cause analysis consider the following in a collaborative setting that allows for dialogue.
1.What are the major root causes and the impact of the adverse occurrence?
2.Which stakeholders are relevant to your adverse effect? Why?
3.What information is needed to perform a root cause analysis?
4.Which tool would you use to create a root cause analysis? Why?
After the root cause analysis is complete address the following questions:
1.What other kinds of information would be helpful? Why?
2.What approach did the team take?
3.What information did you use in your root cause analysis?
ROOT CAUSE ANALYSIS 2
Root Cause Analysis
Cleveland Clinic, Ohio is one of the health care facilities in the United States that have a severe adverse occurrence reported
and that should urgently conduct a root cause analysis. The process through which health care organizations identify the causes and
effects of adverse events are known as root cause analysis. According to Bowie, Skinner, and Wet (2013), health care organizations
should frequently conduct root cause analysis on their systems in order to identify possible areas of change and to come up with
appropriate recommendations that should be implemented to prevent the occurrence of adverse events. Cleveland Clinic has recorded
the occurrence of severe adverse events in its Cardiology Department, especially in the Elderly Services unit. The severe adverse
events recently recorded in the Elderly Services unit of Cleveland Clinic include medication errors (drug reaction), surgery errors,
patient falls, patient elopements, and security breaches in secured areas (Grasso and Jaber, 2014).
The root cause analysis process that Cleveland Clinic, Ohio should use to identify the actual causes of the recorded adverse
events involves five steps that should be performed in a chronological manner. The organization should begin by describing the nature
of the severe adverse events, which should be followed by gathering data associated with each and every one of them. The data that
should be gathered should be related to the severity of the impact, occurrence, and priority risks. After gathering relevant data, the
management of Cleveland Clinic should identify the potential causes of the adverse events followed by the establishment of their
potential impacts. In the final step, the organization should identify possible solutions that should be implemented to bring about a
ROOT CAUSE ANALYSIS 3
positive change (Charles, Hood and Hake, 2016). The root cause analysis of Cleveland Clinic, Ohio on the reported severe adverse
events has been provided in the appendix section of this essay.
The major root causes and the impacts of the adverse events recorded at Cleveland Clinic, Ohio has been included in the root
cause analysis provided in the appendix section. According to Dastjerdi, Khorasani and Ahmadzade (2017), the information that is
needed to perform a root cause analysis should include the potential failure modes of the adverse events, the potential failure effects of
the adverse events, their severity, their potential causes, their occurrence rates, the current control processes that are used by the
organization, probability of detection, the recommended actions that should be implemented to bring about positive change, the risk
priority numbers, as well as stakeholders who are relevant to the severe adverse occurrences. The tool that has been used to create a
root cause analysis for the severe adverse occurrences at Cleveland Clinic, Ohio is Failure Mode and Effects Analysis (FMEA) as
described by Dastjerdi, Khorasani, and Ahmadzade (2017).
For Cleveland Clinic, Ohio to make meaningful change on its system, it should obtain additional information that is not
included in the root cause analysis that is included in the appendix section of this essay. The other kinds of information that would be
helpful include the severity of the impact, occurrence, probability of detection, and risk priority numbers for all the adverse events.
This information is important because it will help Cleveland Clinic, Ohio to understand the seriousness of the effects on its
performance, the frequency at which the adverse events occur, its ability to detect the events before serious impacts are felt, and to
gain an understanding of the nature of risk that the adverse events impose on the organization (Dastjerdi, Khorasani, and Ahmadzade,
ROOT CAUSE ANALYSIS 4
2017). The other information that would be helpful during root cause analysis is stakeholders that are relevant to the specific adverse
effects that have been recorded in the organization. The stakeholders that are involved in the adverse events at Cleveland Clinic, Ohio
are physicians, registered nurses, chief nursing officers, licensed practical nurses, and security personnel. Information about
stakeholders would be helpful because it will guide Cleveland Clinic, Ohio to know specific people that it should involve in
implementing change in the organization (Carayon and Wood, 2011).
The approach that has been taken by the team at Cleveland Clinic, Ohio to create the root cause analysis is the Failure Mode
and Effects Analysis (FMEA). Using a Failure Mode and Effects Analysis tool of root cause analysis, the team has been able to
identify acts that are considered as potential failures with the aim of establishing the best recommendations that the hospital should
implement to avoid the occurrence of similar adverse events in future (Dastjerdi, Khorasani, and Ahmadzade, 2017). The specific
information that has been used in the root cause analysis includes the potential failure mode, potential failure effect, potential causes,
and recommended action. The Cleveland Clinic, Ohio should use the information presented in the root cause analysis to take
corrective actions that will minimize and prevent occurrence of adverse events in its Cardiology Department, especially when health
care practitioners are delivering care to elderly patients (Bowie, Skinner and Wet, 2013; & Charles, Hood and Hake, 2016).
ROOT CAUSE ANALYSIS 5
References
Bowie, P., Skinner, J. & Wet, C. (2013). Training health care professionals in root cause analysis: A cross-sectional study of post-
training experiences, benefits, and attitudes. BMC Health Services Research, 13: 50.
Carayon, P. & Wood, K. (2011). Patient safety: The role of human factors and systems engineering. Studies in Health Technology and
Informatics, 153: 23-46.
Charles, R., Hood, B. & Hake, M. (2016). How to perform a root cause analysis for work up and future prevention of medical error: A
review. Patient Safety in Surgery, 10: 20.
Dastjerdi, H., Khorasani, E. & Ahmadzade, S. (2017). Evaluating the application of failure mode and effects analysis technique in
hospital wards: A systematic review. Journal of Injury and Violence Research, 9(1): 51-60
Grasso, A. W. & Jaber, W. A. (2014). Cardiac risk stratification for non-cardiac surgery.
ROOT CAUSE ANALYSIS 6
Appendix 1: Root Cause Analysis: Cleveland Clinic, Ohio
Adverse Occurrence Potential Failure Mode Potential Failure Effect Potential Causes Action Recommended
1.Medication errors Improper drug combination Drug reactions which lead to
dissatisfied patients
Limited pharmaceutical
knowledge
Rigorous training in
pharmacology and
pharmacokinetics
2.Surgery errors Performance of wrong
surgical procedure
Severe cardiac complications
and the need to spend more time
and resources to perform the
right procedures
Clinician does not pay
attention to detail
Impose strict penalties for
clinicians who fail to adhere to
the standard operating
procedures
3.Patient Falls Forcing adult patients to use
staircases
Increased cases of falls and
physical injuries
Lack of demarcated
highways to be used by
elderly patients
Demarcate highways for elderly
patients who are at risk of falls
4.Patient elopements Patients getting out of the
facility without following the
right discharge procedures
The hospital loses a lot of
money due to unpaid bills
Inadequate security
personnel at the facility
exit
Employ additional security
personnel to monitor movement
of people at the facility exit
ROOT CAUSE ANALYSIS 7
5.Security breaches
in secured areas
Increased number of people
found in unauthorized and
secure places
The hospital is compelled to
incur medical expenses for
people who suffer severe health
consequences while in the
secured places
Lack of warning signs to
prevent people from
entering secured places
Provide warning signs in all
secured places in the facility’s
compound