Describe the proximate factors. (Framework for Conducting a Root Cause Analysis and Action Plan article from The Joint Commission will help. You do not need to complete the framework but may find it useful in discussing the problem.)

In 2010 The Joint Commission reported that the top four root causes for reported sentinel events were lapses in communication leadership assessment and human factors. Describe a high-risk situation (med errors in peds settings) in which at least one of these four elements would be considered a root cause. Address the following areas:Describe what happened.
Explain why it happened.
Describe the proximate factors. (Framework for Conducting a Root Cause Analysis and Action Plan article from The Joint Commission will help. You do not need to complete the framework but may find it useful in discussing the problem.)
Discuss the risk-reduction strategies that were used or that would have been effective.Suggested REcourses:
Dews 2002 article Using Root Cause Analysis to Make the Patient Care System Safe from ASQ World Conference on Quality and Improvement Proceedings pages 651655.
Read Mastal Joshi and Schulkes 2007 article Nursing Leadership: Championing Quality and Patient Safety in the Boardroom from Nursing Economics volume 25 issue 6 pages 323330.
Read Zinns 2008 article Heading into the Unknown: Everyday Strategies for Managing Risk and Uncertainty from Health Risk & Society volume 10 issue 5 pages 439450.
The Joint Commission Web site for the article Framework for Conducting a Root Cause Analysis and Action Plan.

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