COURSE

NURS-4220K Leadership Competencies-Summer

Review the case scenario included in this week’s media resources, and examine the process flow chart, cause/effect diagram, and Pareto chart related to the case scenario.

In the scenario, the nurse manager and the director of pharmacy blame each other for the error. The facilitator (quality assurance person) asks everyone to avoid blaming and focus on applying the tools to analyze the data and get to the root cause of the error. While all of these tools contribute, for this Discussion, select one tool to analyze.

By Day 3

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.

By Day 7

Read and respond to the postings of two or more of your colleagues’ who discussed different charts, identified different evidence of positive collaboration, and/or identified different contributing factors than you did. Also offer comments that ask for clarification, provide support, or contribute additional information. Offer alternative viewpoints on the cause as you see it.

SOLUTION

The RCA team is made up of the risk manager, a registered nurse, and a pharmacy technician. A root cause analysis is “a structured process for identifying the underlying factors that caused an adverse event” (Spath, 2018, p. 209). The risk manager is important because they manage what can compromise a patient’s safety. The registered nurse works on the unit and is aware of how mediation administration is performed. ….Please click the icon below to access entire solution at $5