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Organizational Systems and Quality LeadershipTask 2Ralph SpencerWestern Governors University
C489 Task 2 (1217)1A1. Explain each of the six steps used to conduct an RCA, as defined by IHIThe root cause analysis (RCA) is a standardized process to understand the cause of an adverse event. A RCA is not a punitive or investigative step on an individual to place blame, but more importantly it is designed to look at the process and determine where a mistake was made and then determine how to decrease the chance that an adverse event occurs again. A RCA can be created after a: near miss, incident report, medication error and customer or employee complaint. The RCA team should be interdisciplinary and include all staff who would be directly involved in the event. The first step is to identify what happened, this description must be as accurate and complete as possible. Sometimes a flowchart can be created in order to visualize the process. This is the fact finding step of the process. Full understanding of how the error was performed, by review of the medical record and incident report, is important in order to be accurate. The data collection should not be performed by anyone involved in the error. The second step is to determine what should have happened. Utilizing a flow chart with the correct policy or procedure will aid in finding where the error or near miss occurred. Comparing the actual sequence of events with internal policies and procedures and utilizing the flow chart will show where variation has occurred in care. The third step is to determine the cause. This is where you look at the direct as well as the contributory causes that led to the error. A fishbone diagram can be useful during this step in order to determine a cause and effect flow. Many RCAs recommend asking “Why” repeatedly inorder to find the exact issue that caused the problem. The fourth step is to develop a causal statement that links the cause to the effect and then the main event that caused the creation of the RCA. It's important to assign accountability for
C489 Task 2 (1217)2implementation or change in policy and procedure in order to make change. Changes in the policy should have measurable outcomes or metrics in order to further refine the process.The fifth step is to generate a list of recommended actions to prevent recurrence of the event. A list can include such items as standardization of policies, redundancy in a procedure to insure compliance, use of checklists and simplification of a process. A timeline should be created to evaluate the effectiveness of the policy change and revision should be performed if needed. The sixth and final step is to create a document or summary and then distribution. Clarification of the process and how the event occured can aid in reducing any more errors beingcreated. By disseminating the results hospital wide, patient care will benefit reduction in sentinelevents will increase patient satisfaction and employee morale.