C489_Task_2_Complete-2.docx - Running head ORGANIZATION...

Running head: ORGANIZATION SYSTEMS AND QUALITY LEADERSHIP - TASK 2 1
Organizational Systems and Quality Leadership – Task 2
Yen My Le Nguyen
Western Governors University

ORGANIZATION SYSTEMS AND QUALITY LEADERSHIP - TASK 2 2
Organizational Systems and Quality Leadership – Task 2
A. Root Cause Analysis
A root cause analysis is widely used in healthcare as a tool to analyze errors of an adverse
event (Huber and Ogirnc, 2016). It is a systematic method to identify the fundamental causes,
which can be corrected to prevent future recurrences.
A1. Six Steps of Root Cause Analysis
The Institute of Healthcare Improvement has identified a six-step process when
conducting a root cause analysis (Huber and Ogirnc, 2016). The first step is to identify what
happened. The designated team will gather information about the adverse event and try to
describe what happened accurately. The information comes from all the possible sources such as
the incident reports, staff interviews, patient’s charts and medical record reviews. The second
step is to review what could or should have happened if the hospital and the staffs implement a
good procedure. By comparing what happened and what should have happened in step 1 and step
2, the team can see what the differences are and where the problems occurred. The third step is to
determine the causes of the event. In this step, the team will identify both the causative factors
and contributing factors. While the causative factors are the obvious reasons leading the
outcome, the contributing factors are usually the underlying problems that are needed to be fixed.
The contributing factors are usually grouped into common categories related to healthcare
practices such as patient characteristics, task forces, individual staff member, team factor, work
environment, organizational factors and institutional context (Huber and Ogirnc, 2016). The
fourth step is to develop causal statements to explain how the contributing factors lead to the
unpleasant outcome. The causal statements have three parts: the causes, the effects and the events
(Huber and Ogirnc, 2016). The fifth step is to generate a list of recommended actions to prevent
Updated 6.13.2017

ORGANIZATION SYSTEMS AND QUALITY LEADERSHIP - TASK 2 3
the recurrence of the event. Afterward, the final step is to write a summary and present it to the
leadership, staff and others involved in the event.
A2. Causative and Contributing Factors
The root cause analysis is applied to the stated scenario
Step 1: Define what happened
Mr. B was brought to the hospital. Upon assessment by nurse J, Mr. B’s vital signs on
arrival were blood pressure 120/80, heart rate 88 and regular, temperature 98.6, and respiratory
rate 32. Mr. B appeared to be in distress and severe pain to his hip from a recent fall. Mr. B’s left
leg also appeared shorter than right with swelling and edema to the left calf. Pain was rated ten
out of ten on the numerical pain scale. Medical history was obtained. Assessments were done
by nurse J and ER Physician Dr.T. Then tests were ordered for Mr. B. After evaluation of Mr.B,