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Running head: RCA AND FMEA 1 Root Cause Analysis and Failure Mode and Effects Analysis C489 Task 2 Kelly Coelho Western Governors University
RCA AND FMEA 2 Root Cause Analysis and Failure Mode and Effects Analysis A1. Root Cause Analysis is a systematic process used by workers in the healthcare field to determine the “root cause” of errors that occurred and that can be prevented from happening again in the future. According to the Institute for Healthcare Improvement (2018), before the six steps for an RCA can be conducted, a team must be formed. Teams usually consist of 4-6 different professionals who represent different levels of the organization and who have knowledge of the incident as well as the processes that were involved. There are six steps involved in conducting an RCA. Step 1 is identifying what happened. In this step, the team must try to accurately and correctly determine what happened in the scenario. In step 2, the team is to determine what should have happened under ideal conditions. In step 3, the team should determine causes by “asking why 5 times”. In step 4, the team should develop causal statements. A causal statement links the cause to its effects, and then back to the event that prompted the RCA in the first place. In step 5, the team generates a list of recommended actions to prevent recurrence of the event. In step 6, the final step, the team writes a summary and shares it to be able to further clarify the event (Institute for Healthcare Improvement [IHI], 2018). A2. Step 1 in the RCA is to identify what happened. In the given scenario, the patient is a 67 year old man named Mr. B who broke his hip from a fall at home. He was then taken to short staffed emergency room in a rural hospital. Dr. T, Mr. B’s physician, initially ordered 2 doses of both 5 mg of Diazepam and 2 mg of Hydrophone to be administered to Mr. B. Diazepam is a muscle relaxer and Hydromorphone is used for pain management and sedation. Dr. T ordered these with the goal of moderately sedating Mr. B and relaxing his skeletal muscles, so that manual manipulation to relocate Mr. B’s hip could be performed. Within 10 minutes of nurse J
RCA AND FMEA 2 administering the medications, the desired effects were achieved and Dr. T was able to perform the procedure without any complications. The first mistake is that Mr. B was not connected to any cardiac monitors, even though it was hospital policy that patients under sedation should be connected to a cardiac monitor. Due to other patients being admitted, the staff was also not able to keep as close an eye on Mr. B as should have been kept. To better be able to monitor Mr. B, nurse J placed him on pulse oximetry and automatic blood pressure every 5 minutes. Mr. B’s son was present in the room with him. The second mistake was that there was no intervention when his blood pressure readings started to decrease and his oxygen saturation lowered to 92%. The LPN just reset the blood pressure and oxygen readings and left the room. Step 2 of the RCA,