C489 TASK 22C489 Task 2A1. Explain each of the six steps used to conduct an RCA, as defined by IHI.The purpose of conducting a root cause analysis (RCA) is to look at the facts of how an event occurred and determine the cause of it to keep the event from reoccurring. This is the process by which a RCA is conducted.Step 1- Identify what happened- Concentrate on keeping information as pertinent, factual and accurate as possible and refrain from including opinions. Make sure to include enough detail to tell exactly how the event happened. The data should be collected, and a report should be completed by someone who was not involved in the error originally. Step 2- Determine what should have happened- Charts and graphs can be used to compare the policies that are in place currently to what error occurred. Step 3- Determine the cause of the error- The reviewer should look at all indirect and direct causes to narrow down how the error exactly occurred.Step 4- Develop a causal statement that states the causative factor clearly, the effect the cause had on the dependent variable and then finally how the error resulted. Within this step in the process, assignment of responsibility for changes to existing policies or the implementation of new policies are given to RCA team members to help prevent events reoccurring in the future. It is stressed by IHI that if a policy is going to be changed, there must be ways to measure the outcome, so that the policy may be refined and perfected.Step 5- Generate a list of recommended actions to prevent recurrence of the event- Included in the list would be policies that were refined, checklists that were implemented to prevent reoccurrences of errors and ways that a complicated process has been simplified. Also
C489 TASK 23include a timeline to define when the changes will be implemented and evaluated for effectiveness. Step 6- Create a summary of the event and distribute the summary to pertinent parties- The main goal her would be to keep additional events/errors from happening as well as to improve the care delivered to patients.A2. Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome.Step 1- The patient was on continuous Blood Pressure and Oxygen Saturation monitoringbut when the Licensed Practical Nurse (LPN) went into his room they reset the alarm and then failed to follow through with delivering the assessment findings to the Registered Nurse (RN) or Doctor.