Chapter 13 introduces the root cause analysis (RCA) as a tool for addressing singular adverse events and unsafe situations (p. 260). This week you will have a root cause analysis using a worksheet from the Joint Commission as a guide (included in your Instructional Resources section). Read the case study in Exercise 13.2 and complete the instructions at the end of the case study. After completing Exercise 13.2, discuss your process and results. What do you suspect are the root cause(s) of this issue? What are some of the causal factors? What additional information could help with this analysis if any? Please note, you do not have to submit your worksheet as part of the discussion question.

Exercise 13.2 Objective: To practice addressing the questions in The Joint Commission's "Framework for Conducting a Root Cause Analysis and Action Plan." Instructions: Download The Joint Commission framework from www. jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/rca_framework_101017.pdf. Read the following case study. Follow the instructions at the end of the case study. Case Study: The letter in this case study is adapted with permission from Trina Bingham, a student in the nursing master's degree program at Duke University School of Nursing in 2005. You are the risk manager of a tertiary care hospital and have just received the following letter from a patient who was recently discharged from your facility.

Dear Risk Manager, Last month, I had surgery at your hospital. I was supposed to have a short laparo-scopic surgery with a discharge by lunch, but it turned into an open surgery with complications. This led to a four-day hospital stay and discharge with a Foley cath-eter. Overall, my hospital stay was OK, but I had a situation when the call bell was broken. It was during the night, and I was alone. I needed pain meds. I kept ringing the call bell and no one answered. I used my phone to call the switchboard and no one answered. I didn't want to yell. My IV began beeping (to be honest I kinked the tubing to make it beep), but no one came with that noise either. Eventually the certi-fied nursing assistant came to routinely check my vitals and she got a nurse for me. They switched call bells, but apparently there was an electrical problem, and the call bell couldn't be fixed until the next day, when maintenance was working. The CNA told me to "holler if I needed anything" as she walked out, closing the door. I was so mad, but by this time, the IV pain med was working and I was dozing off. I reported the situation again on day shift and spoke to the director of nursing and the quality assurance manager. Upon discharge, I included this dangerous and unethical situ-ation on my patient satisfaction survey. For me, it worked out OK. All I needed was pain medicine, but what if I had needed help for something more serious? But I have to wonder, when these data are combined with all the other data, if my experience will be minimized. Depending on the layout of satisfaction and quality of care survey results, this situation could look very minor. For all I know, my dissatisfaction was under the heading "dissatisfied with room." I am writing to you because I have not heard from the director of nursing or the quality assurance manager about what they have done to fix the problems. I believe it is important that you hear my complaint so other patients will not have to go through the terrible experience that I did.

To fix the problems described in this patient's letter, you realize you must first understand the root causes of the problems. Brainstorm possible responses to the questions in "A Framework for Conducting a Root Cause Analysis and Action Plan" by The Joint Commission (2017).

please provide scholar sources to support your statement.