Our ConsultantsRoot Cause Analysis
Sometimes things can go wrong; an elopement, a serious medication error, a quality of care issue. When these events happen, the DOH looks at what procedures and policies are in place to investigate accidents and incidents. How does the facility engage in meaningful root cause analysis. Has the required investigation of the incident taken place that includes evidence of gathering and staff interviews? Facilities have been cited at the Immediate Jeopardy level and have been subject to fines and bans on admissions. Unfortunately, all too often, the deficits found are policies and procedures, staff education, or quality assurance activities that have failed to identify or correct vulnerabilities or effectively manage risk.
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