The purpose of this paper is to provide students opportunity to analyze a medical error or near miss situation utilizing a fishbone cause and effect diagram to determine the root cause of the error or near miss.
Paper Preparation:
1. Review: Chapter 3: Quality Improvement Tools, Centers for Medicare and Medicaid Services How to Use the Fishbone Tool for Root Cause Analysis and Guidance for Performing a Root Cause Analysis (RCA) With Performance Improvement Projects (PIPs).
2. View: IHI QI Toolkit and fishbone diagram support resources:
a. Cause and Effect Diagram Video:
b. How to create a fishbone diagram using Microsoft Excel or Smartdraw:
Paper Instructions:
3.Paper is to follow APA (7th ed.) Ground Rules outlined in course syllabus.
4.Paper mechanics:
a.Consistent use of proper grammar, punctuation, spelling, capitalization, and abbreviations; avoid one sentence paragraphs.
b. Limited to 7 pages, excluding title, abstract and reference page.
c.Includes an abstract.
5. Paper is to include a clear, concise, to the point introduction paragraph(s).
6. Paper is to include a response to the following elements:
a.Select an event that resulted or nearly resulted in harm to a patient. Describe the
situation including the people involved, how it happened, the actual or possible harm to the patient and the likelihood of recurrence of the event (almost certain,
likely, possible, unlikely or rare).
b. If you were to assemble a team to work on the root cause analysis for this problem, which team members would you include?
c. Based on your assessment of the event/near miss utilize a fishbone diagram to complete a root cause analysis. Generate the fishbone diagram via computer or use the template provided on BeaconLearning.
i. Identify a problem statement/effect related to this event.
ii. Determine the major causes and factors contributing to the event/near miss event.
iii. Identify all other possible causes of the problem by asking, “Why did this happen?” Utilize the ‘5 Whys’ strategy to generate deeper thinking regarding the causes of the problem in order to address the root cause(s) of the event or near miss situation.
iv. Collate your data on a fishbone diagram. Submit your fishbone diagram to BeaconLearning along with your completed paper.
d. As a nurse leader or educator, based on the results of your root cause error analysis, what two changes in process/procedure would you recommend be tested to reduce the likelihood of another similar event? Consider the following:
i. What safeguards are needed to prevent this root cause from happening again?
ii. What contributing factors might trigger this root cause to reoccur and how can they be prevented?
iii. How could things be changed to make sure that this root cause never happens?
iv. If an event like this happened again, how could the accident trajectory be quickly corrected so that no one was harmed or harm was reduced?
v. What measurements would you use to determine if your suggested change(s) were effective? Who would be responsible for reviewing the data and monitoring the effectiveness of the change(s)?
e. As a nurse leader or educator, what two actions would you recommend to ensure sustainability of the change(s) implemented in this root cause analysis?
f. Include a summary paragraph.
