DEVELOPING A CLINICAL QUESTION ASSIGNMENT INSTRUCTIONS OVERVIEW The effective development

Unit 4 – ROOT CAUSE ANALYSIS WORKSHEET Student Name: Ochuko Omonake Course Section: NSG 4430: Systemic Quality Improvement Instructor: Dr. Shawna Smith 1. THE EVENT – Describe what the event was, what happened, and any harm that resulted. Identify the proximate cause, if known. 2. BACKGROUND & FACTORS SUMMARY- Answer the following questions (brief summary only) 2.1 What was the sequence of events that was expected to take place? Description: 2.2 Was there a deviation from the expected sequence? Yes No If YES, describe the deviation. Attach flowchart if available. 2.3 Was the expected sequence described in policy, procedure, written guidelines, or included in staff training? Yes No If YES, cite source. 2.4 Did human action or inaction appear to contribute to the adverse event? Yes No If YES, describe the actions and how they contributed. 2.5 Did a defect, malfunction, misuse of, or absence of equipment appear to contribute to the event? Yes No If YES, describe what equipment and how it appeared to contribute. 2.6 Was the procedure or activity involved in the event being carried out in the usual location? Yes No If NO, describe where and why a different location was utilized. 2.7 Was the procedure or activity being carried out by regular staff familiar with the consumer and activity? Yes No If NO, describe who was carrying out the activity and why regular staff were not involved. 2.8 Were staff trained to carry out their respective responsibilities? Yes No If NO, describe the perceived inadequacy. 2.9 Were staffing levels considered to have been adequate at the time of the incident? Yes No If NO, describe why. 2.10 Did a lack of communication or incomplete communication contribute to or cause the adverse event? Yes No If YES, describe who and what and how it contributed. 3. RISK REDUCTION ACTIONS TAKEN – List the actions that have already been taken to reduce the risk of a future occurrence of the event under consideration. Action Taken – Description 4. PREVENTION STRATEGIES – Using at least one scholarly source, please identify and describe three prevention strategies that could be used to address the situation. # Strategy 1 2 3 5. STAKEHOLDERS – List and Describe the Stakeholders Needed to Address this Event and Root Cause Analysis Name of Role on the Interprofessional Team The Person’s Association to the Event (briefly identify how the person would be associated with the event) the event

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