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Running head: ORGANIZATION SYSTEMS AND QUALITY LEADERSHIP - TASK 2 1Organizational Systems and Quality Leadership – Task 2Yen My Le NguyenWestern Governors University
ORGANIZATION SYSTEMS AND QUALITY LEADERSHIP - TASK 2 2Organizational Systems and Quality Leadership – Task 2A. Root Cause AnalysisA root cause analysis is widely used in healthcare as a tool to analyze errors of an adverseevent (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 AnalysisThe Institute of Healthcare Improvement has identified a six-step process whenconducting a root cause analysis (Huber and Ogirnc, 2016). The first step is to identify whathappened. The designated team will gather information about the adverse event and try todescribe what happened accurately. The information comes from all the possible sources such asthe incident reports, staff interviews, patient’s charts and medical record reviews. The secondstep is to review what could or should have happened if the hospital and the staffs implement agood procedure. By comparing what happened and what should have happened in step 1 and step2, the team can see what the differences are and where the problems occurred. The third step is todetermine the causes of the event. In this step, the team will identify both the causative factorsand contributing factors. While the causative factors are the obvious reasons leading theoutcome, 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 healthcarepractices such as patient characteristics, task forces, individual staff member, team factor, workenvironment, organizational factors and institutional context (Huber and Ogirnc, 2016). Thefourth step is to develop causal statements to explain how the contributing factors lead to theunpleasant 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 preventUpdated 6.13.2017
ORGANIZATION SYSTEMS AND QUALITY LEADERSHIP - TASK 2 3the recurrence of the event. Afterward, the final step is to write a summary and present it to theleadership, staff and others involved in the event. A2. Causative and Contributing FactorsThe root cause analysis is applied to the stated scenarioStep 1: Define what happenedMr. B was brought to the hospital. Upon assessment by nurse J, Mr. B’s vital signs onarrival were blood pressure 120/80, heart rate 88 and regular, temperature 98.6, and respiratoryrate 32. Mr. B appeared to be in distress and severe pain to his hip from a recent fall. Mr. B’s leftleg also appeared shorter than right with swelling and edema to the left calf. Pain was rated tenout of ten on the numerical pain scale. Medical history was obtained. Assessments were doneby nurse J and ER Physician Dr.T. Then tests were ordered for Mr. B. After evaluation of Mr.B,