For this discussion forum, your initial posting will be a root cause analysis (RCA) that includes an overview of the sentinel event, a fishbone diagram, and the five Why’s associated with one of your possible root causes in the fishbone diagram. Your RCA will be based on one of the scenarios provided under “Materials,” “Course Assignments.” In your discussion group, please ensure that both scenarios are analyzed.
In this discussion, you will propose a solution to one of the possible root causes discovered in your fishbone diagram. Provide an in depth discussion of your proposed solution to the quality/safety issue using the PDSA/PDCA process. Be specific about what you would recommend to the organization to prevent the sentinel event from happening again in the future.
Provide feedback to two others regarding their root cause identification. Did all of you identify the same root cause? Why or why not?