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Improving Patient Safety using Root Cause Analysis

The basis of measuring quality improvement in an organization is that good performance results in good-quality practice. By measuring healthcare quality, organizations can assess whether their services conform with patient preferences and are agreed to by professional consensus. Doing so requires concentrating on the entire system instead of individuals. This concept relates much with the Total Quality Management (TQM) approach that centers on a systematic analysis and measurement of process steps to outcomes.

It involves various activities such as teamwork, defined processes, systems thinking, and change to create an environment that supports improvement. In this view, the entire organization must be committed to improvement to achieve the best possible results using practices such as root cause analysis.

The two major categories of error in systems include active and latent error. The former type happens at the point of contact between human and system, whereas the latter – the focus on the root cause analysis – occurs due to systems design failures. Organizations use root cause analysis to identify prevention strategies by building a safety culture and abandoning the culture of blame.

The main objective is the identification of the causes and mitigation of errors to prevent similar happenings in the future (Govindarajan et al., 2019). It requires the leadership and those close to the systems and processes within the organization to chip in. Beyond uncovering causes of adverse events, systematically applying root cause analysis may suggest changes to the system to prevent similar incidents.

Application of root cause analysis requires established qualitative techniques. After identifying an event, for instance, a critical chemotherapy error or a significant AO incompatible transfusion reaction, a multidisciplinary team is assembled to direct the inquiry. The team members get training in techniques and the purpose of the root cause analysis to revert potential biases.

Relying on different findings on the issue increases the validity of the final results. In essence, the two stages include data collection through means, such as structured interviews and field observation, and data analysis to examine the sequence of events – how and why the event happened.

To culminate the process, the team sums the root causes and begins assessing administrative and systems problems that might be candidates for a restructure. Although there might be insufficient data to support root cause analysis as a proven patient safety practice, it is a crucial qualitative tool that complements other error reduction techniques if applied effectively.

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