Problem: In the scenario, the nurse manager and the director of pharmacy blame each other for the error. The facilitator (quality assurance person) asks everyone to avoid blaming and focus on applying the tools to analyze the data and get to the root cause of the error. Select one tool to analyze, process flow chart, cause/effect diagram, and Pareto chart related to the case scenario.
1. Analyze the composition of the RCA team. Explain what knowledge they can contribute to the RCA.
2. Describe the collaboration in the case study that led to effective problem solving. Identify the evidence you observe in the scenario that demonstrates effective collaboration and the avoidance of blaming.
3. Explain the team's process in testing for and eliminating root causes that were not contributing.
4. Select one of the performance improvement charts presented in the scenario and critique its effectiveness by explaining how it contributes to identifying the root cause and determining a solution to prevent repeat medication errors.
5. Identify the contributing factors and discuss how to prevent this kind of error from occurring in the future.