A step-by-step guide to root-cause analysis
Staff Development Weekly: Insight on Evidence-Based Practice in Education, June 11, 2004
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Training plays a vital role in ensuring that workers act in accordance with established best practices. This is especially true in today's environment of new technology, expanding facilities, and higher performance expectations.
Variation in knowledge, experience, and practice can all lead to sentinel events. For example, an RCA team might investigate a patient's death caused by his or her oxygen tank being mistakenly switched with a nitrogen tank. The root cause might have been the fact that a new orderly was never trained to double-check the label on gas tanks before replacing them.
Editor's note: The above excerpt is from the online course "Nursing CE Series: A step-by-step guide to root-cause analysis." For more information on this and other Nursing courses, go to www.hcprofessor.com and click on Nursing CE.
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