scholarly journals Use of root cause analysis in nursing education: Best practice from the quality and safety officer

2015 ◽  
Vol 5 (7) ◽  
Author(s):  
Elizabeth Cooper ◽  
Susan Pauly-O'Neill
2019 ◽  
Vol 6 ◽  
pp. 238212051989427
Author(s):  
Maya Aboumrad ◽  
Julia Neily ◽  
Bradley V Watts

Background: Clinicians are key drivers for improving health care quality and safety. However, some may lack experience in quality improvement and patient safety (QI/PS) methodologies, including root cause analysis (RCA). Objective: The Department of Veterans Affairs (VA) sought to develop a simulation approach to teach clinicians from the VA’s Chief Resident in Quality and Safety program about RCA. We report the use of experiential learning to teach RCA, and clinicians’ preparedness to conduct and teach RCA post-training. We provide curriculum details and materials to be adapted for widespread use. Methods: The course was designed to meet the learning objectives through simulation. We developed course materials, including presentations, a role-playing case, and an elaborate RCA case. Learning objectives included (1) basic structure of RCA, (2) process flow diagramming, (3) collecting information for RCA, (4) cause and effect diagramming, and (5) identifying actions and outcomes. We administered a voluntary, web-based survey in November 2016 to participants (N = 114) post-training to assess their competency with RCA. Results: A total of 93 individuals completed the survey of the 114 invited to participate, culminating an 82% response rate. Nearly all respondents (99%, N = 92) reported feeling at least moderately to extremely prepared to conduct and teach RCA post-training. Most respondents reported feeling very to extremely prepared to conduct and teach RCA (77%, N = 72). Conclusions: Experiential learning involving simulations may be effective to improve clinicians’ competency in QI/PS practices, including RCA. Further research is warranted to understand how the training affects clinicians’ capacity to participate in real RCA teams post-training, as well as applicability to other disciplines and interdisciplinary teams.


Author(s):  
Trevor Bailey ◽  
Suzanne Woll ◽  
Rajul Misra ◽  
Kevin Otto

This paper presents a model-based systems engineering methodology that can be applied to perform a root cause analysis on transient systems. The methodology extends existing root cause analysis best practice by incorporating system modeling and analysis techniques. The methodology is deployed through a detailed 5-step process to understand, identify, assess, FMEA, and validate potential transient system-level root causes. A transient performance reliability analysis for a dual mode refrigeration system is used to demonstrate how the methodology can be applied. The paper also describes a set of success factors for applying the methodology using a phased approach with a large cross-functional team.


2013 ◽  
Vol 17 (3) ◽  
pp. 29-34
Author(s):  
Colleen Maykut, ◽  
Lisa McKendrick-Calder,

The purpose of baccalaureate nursing education is to foster critical thinking in the nursing student to encourage use of evidence in their practice, increasing their ability to manage complexity in a variety of settings. Nurses who incorporate critical thinking and problem-solving strategies into their practice ensure an evidence-informed approach and become active participants and architects of their own destiny. A root cause analysis approach utilizing The Theory of Bureaucratic Caring as a lens might facilitate critical thinking and problem solving, and enhance the understanding of the dichotomy of a caring bureaucracy; facilitate decision-making; and humanize nursing care (Ray, 1989; Ray & Turkel, 2012, 2010) for the nursing student.


2011 ◽  
pp. 78-86
Author(s):  
R. Kilian ◽  
J. Beck ◽  
H. Lang ◽  
V. Schneider ◽  
T. Schönherr ◽  
...  

2012 ◽  
Vol 132 (10) ◽  
pp. 1689-1697
Author(s):  
Yutaka Kudo ◽  
Tomohiro Morimura ◽  
Kiminori Sugauchi ◽  
Tetsuya Masuishi ◽  
Norihisa Komoda

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