C489 - Organizational Systems Task 21Organizational Systems and Quality LeadershipTask 2Lela LambirthWestern Governors University
C489 - Organizational Systems Task 22A. Root Cause AnalysisA root cause analysis (RCA) is conducted by healthcare facilities following a sentinel event, which is defined by The Joint Commission as a Patient Safety Event that reaches a patient and results in any of the following: death, permanent harm, or severe temporary harm and intervention required to sustain life [The17] . The goal of an RCA is to answer 4 questions: what happened? Why did it happen? What are we going to do to prevent it from happening again? Andhow will we know that the changes we make actually improve the safety of the system? [Ins].A1. RCA StepsThere are six steps to conduct an RCA according to the Institute for Healthcare Improvement [Ins]. The first step is to identify what happened. An interprofessional team of 4-6 people, including a member of the risk management or quality improvement departments, forms to review the sentinel event. A flowchart or timeline should be created to outline the chain of events that occurred and then team members need to collect additional information that may havecontributed to the events through interviews, record reviews, and observations.Step two is to determine what should have happened. Policy review, review of current medical literature, and interviews with staff members to uncover any barriers to safe practice should occur during this step [Ins]. A new flowchart showing what should have happened if the facility had reasonable procedures in place and staff were compliant with those procedures. The original and new flowcharts can be compared side by side to provide the team perspective on what should have happened and what did happen.The third step is where the team determines the factors that contributed to the event [Ins].For each contributing factor the team must ask why it happened and continuing asking why for
C489 - Organizational Systems Task 23each finding. Continuing to ask why something happened aids the team in getting to the root cause of the sentinel event. A fishbone diagram is a useful tool for identifying contributing factors into groups, so they become more apparent by categorizing factors in the following groups: patient characteristics, task factors, individual staff member, team factors, work environment, organizational and management factors, and institutional context.Developing a causal statement is the fourth step in conducting an RCA. The causal statement links the cause that was identified in step three to its effects and then back to the main event that prompted the RCA in the first place [Ins]. The statement itself consists of three parts, the cause, the effect, and the event.
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- Spring '17
- Root cause analysis, Failure mode and effects analysis, RCA