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1Running Head: RCA and FMEA RCA and FMEALaura ZeilerWestern Governors University
2Running Head: RCA and FMEA A.Purpose of Root Cause Analysis (RCA)The Institute for Healthcare Improvement defines a root cause analysis (RCA) as a “systematic approach to understanding the causes of an adverse event and identifying system flaws that can be corrected to prevent the error from happening again” (Institute for Healthcare Improvement.). An RCA looks back on past actions in an effort to learn from past mistakes and grow from them. A1. RCA Process Root cause analysis is made up of six total steps. The first step looks to identify what event occurred and describe it in its entirety. The second steps looks at the steps that should have been taken to prevent the event from happening. The third steps seeks to identify the factors that contributed toward to event occurring. This can also be seen as asking why this occurred. The fourth step has the team develop causal statements in which the cause is linked to its direct effect, and then back to the overall event that caused the team to conduct an RCA. Step five has the team create a list of actions that could be taken to prevent similar events from happening in the future. Lastly, step six asks for a summary to be written, therefore making it easy to share the ideas generated from the RCA with others as well as bring in key stakeholders that would contribute to the implementation of recommended improvement steps. A2. Application of RCA to ScenarioRoot cause analysis can be used to identify contributing factors leading to a sentinel event in scenario provided. Using the first step, we identify that Mr. B, a
3Running Head: RCA and FMEA patient in a rural hospital, was admitted regarding a dislocated hip. The physician (MD) working instructs the registered nurse (RN) to administer sedating medications in an effort to achieve pain control and sedation to allow the MD to manipulate the patient’s leg and return it into place. While the patient was administered these medications, he wasn’t placed on monitoring equipment such as a pulse oximeter or blood pressure monitoring. Following the procedure, the patient is placed on a blood pressure monitor and pulse oximeter and the RN and MD attend to new patients in the emergency room. The machines on the patient begin to set off alarms, to which a licensed practical nurse (LPN) turned off. After some time, the patient’s son alerts staff to the alarms going off.