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Root Cause Analysis at Downtown Medical

The Root Cause Analysis (RCA) team consists of the nurse manager, the director of the pharmacy, and the facilitator. These experts can use their knowledge of administering medication procedures, electronic documentation, medicine ingredients, and the components of identifying the errors’ root causes. The effective collaboration between the nurse manager who attempts to determine the cause and the pharmacist in the case study provides the chance to understand what mistake occurred. The evidence of this collaboration can be the desire of the manager to initiate RCA rather than start blaming the pharmacy without investigation. Consequently, the team members might play a significant role in finding the cause of the error.

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The team creates the fishbone cause-effect diagram to observe possible causes and eliminate the unnecessary components. Mainly, they define that such causes as human factors and equipment and medications’ issues might assist in identifying the roots. At the same time, they collect various ideas to understand that some of them do not contribute to the resolution. For example, the patient’s allergy can not be considered as the cause needed for the examination. A cause-effect diagram is a practical case assessment tool because it provides the opportunity to determine the root cause by considering and evaluating all the possible options. Simultaneously, it demonstrates how healthcare professionals may avoid similar situations by providing a list of areas of concern, which should be analyzed in other cases.

The contributing factors of finding the roots of the mistake include the team members’ readiness to cooperate and the facilitator’s role in combining all the problem’s aspects. However, it would be more effective to prevent this mistake from occurring in other situations. Billstein-Leber et al. (2018) introduce the method of finding the effective “risk-reduction strategies” (p.1495). This approach might help to understand the medication errors and define them before they cause any harm. De Oliveira et al. (2017) offer to make the pharmacists intervene to guarantee that the mistakes do not harm patients. This method can be valuable if the pharmacists have sufficient knowledge and experience. Consequently, these situations can be resolved if the team members cooperate effectively and use various strategies to avoid the issues.


Billstein-Leber, M., Carrillo, C., Cassano, A., Moline, K., & Robertson, J. (2018). ASHP guidelines on preventing medication errors in hospitals. American Journal of Health-System Pharmacy, 75(19), 1493-1517.

De Oliveira, G., Castro-Alves, L., Kendall, M., & McCarthy, R. (2017). Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: A meta-analysis of randomized controlled trials. Journal of Patient Safety, 17(5), 375-380.

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