Root Cause Analysis Team’s Issue and Solution

Subject: Case Studies
Pages: 2
Words: 358
Reading time:
2 min
Study level: College

The members of a Root Cause Analysis (RCA) teamwork collaboratively in order to facilitate problem-solving use for identifying the faults and problems that resulted in an unfavorable healthcare outcome. In the presented scenario, the RCA team is comprised of the Risk Manager, Pamela, a Staff Nurse, Linda, and a Pharmacy Technician, Matthew. Within the team, the role of the risk manager is to consistently assess and minimize the occurrence of different risks to staff, patients, and organizations in general. The staff nurse is responsible for providing high-quality care to patients while the pharmacy technician manages and prepares the supply of medication and gives advice to patients regarding their administration.

While the team meeting began with some blaming for a problem’s occurrence, collaboration was essential for avoiding conflict from developing. Specifically, the entire team recognized that there were errors that all of them had made and that the focus was to be placed on patient safety and quality improvement. Using RCA tools, the team could identify the main inhibitors of success, such as burnout-related errors, inadequate staffing, and IT failures. The tools allowed the team to focus on specific challenges that must be addressed one by one, without spending time and effort on blaming one another.

The Process Flow Chart is a useful RCA tool that the team can use to ensure correct medication administration. Because it breaks down every step of the process, it makes it easier for the team members to isolate each component of the project and make corrections in real-time. The tool contributes to identifying root causes and determining solutions through rationalizing activities and defining roles for the professionals involved (Vilela & de Carvalho Jerico, 2020). The main contributing factors within the flow chart include scanner issues, having to manually enter internal entry numbers, and the need to consult the pharmacy. Improved IT and collaboration with the pharm tech are necessary to reduce the impact of the factors, especially considering the technologies available to help scan barcodes quickly and eliminate human error. Besides, improved staff nurse training is needed alongside increased staffing on shifts to avoid overworked professionals who are more prone to making errors.


Vilela, R., & de Carvalho Jerico, M. (2020). Validation of the Drug Chain Flowchart as a preventive technology for medication errors. Revista O Mundo da Saúde, 44, 325-337.