Adverse Occurrence Root Cause Analysis
click on this link
http://webmm.ahrq.gov/case.aspx?caseID=98
Click “THE COMMENTARY”,on the left side. Then I will need to review the case study and then report on the cause, explain the process of the RCA, and what the results were. If you see “GETTING TO THE ROOT OF MATTER”, on the page then that’s the right site.
……………………………Answer preview………………………….
The cause of root cause analysis (RCA) stems from a clinician’s administration of vasopressin overdose for a patient admitted in the intensive care unit (ICU) with lung cancer, chronic renal insufficiency and atrial fibrillation. The patient was receiving a combination of many other drugs due to his multiple conditions………………………….
APA
563 words