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Dissertation
Implementation of Enhanced Root Cause Analysis Process to Improve Patient Safety
Doctor of Nursing Practice (D.N.P.), Drexel University
22 May 2022
DOI:
https://doi.org/10.17918/00001519
Abstract
Background: Root cause analysis (RCA) is a tool for identifying prevention strategies that use a multidisciplinary team approach to analyze healthcare-related adverse events and near misses. A key to improving patient safety and providing quality care is a thorough RCA process that identifies, reports, reviews, and addresses problems related to adverse events and near misses. Problem: The stakeholders want to improve turnaround time for RCA completion without compromising the quality of the process to improve patient safety and quality outcomes. Improving the RCA process is a local practice problem in the suburban academic medical setting based on data from senior directors of patient safety, risk management, and quality. Methods: A revised RCA workflow process was designed for this quality improvement project using the Plan-Do-Study-Act (PDSA) cycle. The project consisted of implementing an enhanced RCA process to improve the timeliness from RCA declaration to analysis completion to ensure that factors leading to significant events are addressed quickly. The mean time for pre- and post-implementation phases were calculated to evaluate the effect of an enhanced process to improve the timeliness of RCA completion. Results: Comparing pre-intervention and post-intervention mean time for RCA declaration to completion was 79.2 to 31.7 days. A t-test to compare the means of RCA days to completion using a level of significance of 0.05 identified a statistical difference between pre-and post-intervention groups. Conclusions: The new RCA process demonstrated a correlation between the intervention and timeliness of RCA completion.
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Details
- Title
- Implementation of Enhanced Root Cause Analysis Process to Improve Patient Safety
- Creators
- Amy C. Plotts
- Contributors
- Patti Rager Zuzelo (DNP Chair)
- Awarding Institution
- Drexel University
- Degree Awarded
- Doctor of Nursing Practice (D.N.P.)
- Publisher
- Drexel University; Philadelphia, Pennsylvania
- Number of pages
- 61 pages
- Resource Type
- Dissertation
- Language
- English
- Academic Unit
- Doctoral Nursing; Nursing (Graduate); College of Nursing and Health Professions; Drexel University
- Other Identifier
- 991020220770504721