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the Joint Commission defines a root cause analysis (RCA) as “a process for identifying the factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event.” The focus of a root cause analysis should be on systems and processes rather than on individual performance, and the product of this analysis is an action plan that identifies strategies to reduce the risk of similar events occurring in the future. Action plans should address responsibility for implementation and oversight, pilot testing (when appropriate), timelines, and measures of the effectiveness of the plan.
After completing the case study assignment, complete the discussion board’s initial post.
In your initial post, please discuss the following and be sure to support your statement with information from the course materials and other scholarly references.
Post your fishbone analysis flowchart as an attachment
Discuss what process breakdowns you discovered in Carla’s case.
Discuss how a Respiratory Therapist could use Root Cause Analysis to improve patient outcome.
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