634130517_root_cause_analysis - Running head ORGANIZATIONAL...

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Running head: ORGANIZATIONAL SYSTEMS & QUALITY LEADERSHIP 1 Organizational systems & quality leadership Student Institution
ORGANIZATIONAL SYSTEMS & QUALITY LEADERSHIP 2 A. Complete a cause analysis (RCA) that takes into consideration causative factors, errors, and hazards that led to the sentinel event (this patient’s outcome). Root cause analysis is a structured and teamwork procedure that allows the establishment of the cause of a problem at hand and enhance the creation of strategies that will prevent similar undesirable outcomes in future (Williams, 2001). The following steps can be used to conduct a root cause analysis. It starts by identifying the event to be investigated by gathering preliminary information. The event in this context is the death of the Mr. B; the preliminary information is gathered by checking through his medical history. He has a history of high lipid and cholesterol levels; he also had glucose intolerance and prostate cancer. The second step is to charter a facilitator of a team and its members whose to investigate the case (Hughes, 2008). The team will compose all the officers who served him from triage room to the point he lost his life. The third step is describing all activities that happened before he died. He has admitted to the triage room serviced and discharged to the emergency room. The patient is actively sedated using hydromorphone and diazepam both intravenous also to help relieve pain. The next step is identifying circumstances that might have led to the event. His medical history of glucose intolerance, prostate cancer, high levels of cholesterol and lipid levels were never given any attention apart from the hip. The fifth point is identifying the root causes; Mr. B was discharged from triage room and actively sedated and his pain relieved, from his medical history it shows he had issues of blood pressure and cancer which the facility did not address. They only placed him under monitors but not intervention was in place this greatly contributed to his death. The sixth step involves the team coming up with a procedure that will eliminate similar root causes in
ORGANIZATIONAL SYSTEMS & QUALITY LEADERSHIP 3 future. The triage should have recommended other vital consideration once transferred to the

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