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Root Cause Analysis

Failure Modes and Effects Analysis (FMEA) is focusing on safety in systems and
prevention of accidents according to Finkelman and Kenner (2012). According to Abdollahi
(2014), root cause analysis (RCA) is the technique for understanding the systematic error causes
that is involved beyond a person or people to implement an errors and including field and
environmental causes of errors when occur in this situation too. Both of these tools are
important to finding out the problem and reasons and implementing a plan to correct the causes
of errors. The main difference is FMEA attempts to determine the cause of failure before which
is proactive. The RCA is a reactive process for evaluation after the error has occurred which is
reactive. (Fibuch and Ahmed, 2014).
For my example I am using a medication error that happened at my facility which would
be RCA. During the day and early evening shift a change in the way a resident was acting had
taken place. He acted like he was out of it. By the time we arrived, he was back to his baseline.
That night for his midnight dose of medication was noted to be missing from the bubble pack
card. We checked for variances in the medication record and charting. No documentation was
found. We gave him the dose from a later date in the month and reordered the missing dose.
Through our findings we discovered the medication card for the midnight dose was placed in
front of the day dose after being given the previous night. The previous night we had a new
certified medication aid giving medications. The facility had gone to a new system with times
and no separation between the shifts or color designations on the cards for the different shifts and
times to administer. So, this was considered a systems error with the new system for medication
not being labeled for different times to administer and no separation between the times to alert
the medication passers. Also, the education of placing the medication cards after given to the

back of the section for that resident's medications. This was taken to the interdisciplinary
committee. Changes were made of adding cards between the shifts with color coding and circling
the med times on the cards. A re-education was sent out to medication passers to place the cards
in the back of the section for the resident after being given. A review of the rights of medication
administration was, also, sent out as re-education. This was the first time I have seen this process
used at the unit level. In the past this would have been very punitive and pointing fingers
resulting in discipline.

Abdollahi, A., (2014). Root cause and error analysis. Iranian Journal of Pathology, 9 (2): 81-88.
Fibuch, E. & Ahmed, A., (2014). The role of failure mode and effects analysis in health
care. PEJ, July-August: 28-32.
Finkelman, A. & Kenner, C., (2012). Learning IOM: Implications of the institute of medicine
reports for nursing education. Silver Springs MD.