Healthcare organizations accredited by the Joint Commission are required to conduct a root cause analysis (RCA) in response to any sentinel event, such as the one described in the scenario attached below. Once the cause is identified and a plan of action established, it is useful to conduct a failure mode and effects analysis (FMEA) to reduce the likelihood that a process would fail. As a member of the healthcare team in the hospital described in this scenario, you have been selected as a member of the team investigating the incident.
Scenario:
You can find the scenario attached below in the
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