HUO Development of Strategic Planning in Healthcare Root Cause Analysis Worksheet

The death of a patient (as described in the Real Life Scenario (text Chapter 11, pages 233-234) is always classified as a sentinel event. The Joint Commission requires the organization to do a root-cause analysis when such an event occurs. The purpose of the analysis is to discover what processes led to the occurrence. In this assignment, students will use the “cause and effect fishbone diagram” which is the most commonly used technique used in a root cause analysis. This exercise will give students experience in conducting the root cause analysis that is used in actual hospital situations.


  • After reading Chapter 11 in the text, review the Real Life Scenario on pages 233-234 about Dr. Low and his patient Mrs. Yu.
  • Your assignment is to complete the Root Cause Analysis document attached.
  • There is no outside research required for this assignment; all the information you need is included in Chapter 10.
  • This is a template model for analyzing a sentinel event, so not all of the questions will apply to the case scenario that the students are asked to analyze.
  • How to fill out the template for Root Cause Assignment:
    • Columns 1 & 2 (titled “Level of Analysis”) are just for guidance.
    • Students should focus on Column 3’s Questions, answering them in the “Findings” column 4.
    • Columns 5-7 for Root Cause/Ask Why and Take Action can be used to indicate whether the findings described in the “Findings column” are part of the root cause, whether we need more information to answer the question, or whether we need to take some action.
    • Students would put a check mark or a Y/N in each box to say whether the findings are part of the root cause/ask why (more info)/take action.
    • For any Findings that are marked “take action” in column 7, students should suggest a Risk Reduction Strategy on the last page of the template.
  • Again, this is a template so it’s possible that not every question will apply to the case scenario. Students should complete as many of the questions as they can be based on the information provided in the case scenario.

Assignment 2

Step One: The Office of the National Coordinator for Health Information Technology (ONC) Health IT Certification Program helps to ensure that health IT conforms to the standards and certification criteria adopted by the Secretary of Health and Human Services. The Office of Health IT Certification was established to develop and oversee national programs for the certification of health information technology by the Health Information Technology for Economic and Clinical Health (HITECH) Act. Health IT certification provides assurance to purchasers and other users that a system meets the technological capability, functionality, and security requirements. Review the ONC Health IT Certification program – (Links to an external site.).

Step Two: To ensure the requirements are met, ONC Health IT developed a set of functional and conformance testing criteria for certification. Review the ONC Health IT Testing Requirements page – (Links to an external site.)

Step Three: Go to 170.315(b)(3): Electronic Prescribing and read the companion guide

(Links to an external site.)

Step Four: Also for 170.315(b)(3): Electronic Prescribing, read the test procedure

(Links to an external site.) (see second tab)

Step Five: Also for 170.315(b)(3): Electronic Prescribing, go to the test tool and then to the Electronic Prescribing (eRx) link

(Links to an external site.) (see third tab)

Step Six: Once in the eRx tool, click on the green “Structured SIG Testing: Start Testing” button to use the tool. You will need to register which is free and instantaneous.

Step Seven: After registering, login using your new credentials. Go into a Test Case and a Test Step by clicking on “test selection” in the top menu bar. Use the left menu to select test cases/scenarios – be sure to expand the case fully to reveal the “test story” page. Take a screen shot of the example message that you see.

Step Eight: Submit your screen shot, along with a 2-3 page summary detailing what you learned as you reviewed the ONC criteria for grading. Ensure that you include a discussion of the importance of the concepts of vocabulary, language, terminology, and nomenclature. Your summary with screen shot should be in Microsoft Word format. Cite all sources in APA format.

Expert Solution Preview


As a medical professor, I am responsible for creating assignments and evaluating the performance of medical college students. In this assignment, students will apply the cause and effect fishbone diagram to conduct a root-cause analysis of a sentinel event. They will not require external research for this assignment, and they will have to complete the Root Cause Analysis document attached based on Chapter 11 of the textbook. Furthermore, this assignment requires students to review the ONC Health IT Certification Program, the functional and conformance testing criteria, and take a screen shot of the example message that they see.

1. Why is the Joint Commission required to do a root-cause analysis when a death of a patient occurs?

The Joint Commission mandates Root Cause Analysis (RCA) when a sentinel event occurs, such as the death of a patient. The purpose of RCA is to analyze the cause and effect relationship of the event to determine the underlying process breakdown that occurred leading to the incident.

2. What is the cause and effect fishbone diagram, and why is it used in a root-cause analysis?

The cause and effect fishbone diagram is the most frequently used technique in a RCA. It is a visual tool that assists in identifying the primary cause of an issue by mapping out relationships between the potential contributing causes. It is used to systematically locate the root cause of an error, defect, or issue.

3. What is the purpose of ONC Health IT Certification Program, and how does it help with electronic prescribing?

The purpose of the ONC Health IT Certification Program is to ensure that the health IT systems conform to the standards and certification criteria adopted by the Secretary of Health and Human Services. Specifically, it helps to certify the electronic prescribing system requirements, which include technological capabilities, functionality, and security.

4. Why is it important to review the ONC criteria for vocabulary, language, terminology, and nomenclature?

It is essential to review the ONC criteria for vocabulary, language, terminology, and nomenclature because they are the foundation of accurate and reliable health data. Standardized nomenclature and terminology help to ensure that health information is consistent, accurate and accessible across various healthcare settings and providers. Without standardized terminology, healthcare providers may have difficulty communicating with each other leading to errors, inefficiencies, and poor quality of care.

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