C489 RCA and FEMA Task 2.docx - Running Head ORGANIZATIONAL SYSTEMS RCA and FEMA Task 2 Tara Andre Western Governor\u2019s University RCA AND FMEA 2 ROOT

C489 RCA and FEMA Task 2.docx - Running Head ORGANIZATIONAL...

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Running Head: ORGANIZATIONAL SYSTEMSRCA and FEMA Task 2Tara AndreWestern Governor’s University
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RCA AND FMEA2ROOT CAUSE ANALYSISThe Institute for Healthcare Improvement defines a Root Cause Analysis (RCA) as “a process widely used by health professionals to learn how and why errors occur” (Institute for Health Improvement, 2018). A Root Cause Analysis facilitates understanding exactly what happened to cause a sentinel or an adverse event and how to design a plan to keep it from occurring again. The RCA is conducted by a multidisciplinary team in order to have a broad range of knowledge available during the process. The Root Cause Analysis is a proven evidence-based method.RCA STEPSThere are six steps involved in conducting a Root Cause Analysis. The first step is to figure out exactly what happened. This is the time to collect information and to investigate to gain a clear picture of the incident. The second step is to determine what should have happened in an ideal situation. The third step is to determine the causes and contributors. Were there factorsor a single direct cause that contributed to the event? Asking why five times is a principal part of the third step which includes not accepting the first answer you get but to continue asking why until you determine the actual cause. The fourth step is to develop causal statements. The way to create casual statements is to determine the cause, the effect, and the event. The fifth step is to recommend actions and the sixth and final step is to write a summary to share in order to help prevent the incident from occurring again (Institute for Healthcare Improvement, n.d.). CAUSATIVE AND CONTRIBUTING FACTORSThe most effective and comprehensive way to analyze the causative and contributing factors to the task scenario is to conduct a Root Cause Analysis. The first step is to determine what happened. Mr. B was a 67-year-old male admitted to the emergency room for a left-
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RCA AND FMEA3dislocated hip after he suffered a fall at home. On duty, that day was Registered Nurse J, an LPN,a secretary, an emergency room physician, Dr. T, and a Respiratory Therapist was available as well. Mr. B’s pain was 10 out of 10 meaning he was in severe pain. Mr. B also had a history of taking a narcotic pain medication called Oxycodone. When Mr. B arrived at the ER there were two patients being cared for, one waiting for discharge and one with pending lab results. Both patients had been triaged and cared for. Mr. B needed to have a procedure to correct his dislocated hip which required him to have sedation for pain control and relaxation. Dr. T instructs Nurse J to administer conscious sedation medication. Mr. B is given an initial dose of 5 mg of Diazepam and 2 mg of Hydromorphone which fails to provide the level of sedation Dr. T feels is appropriate for the procedure, so those same doses are repeated for a total of 10 mg of Diazepam and 4 mg of Hydromorphone. Dr. T makes note that after he reviewed Mr. B’s medicalrecord that his weight of 175 lbs. and already taking narcotic pain medication contributed to the
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  • Fall '18
  • Nursing, RCA, Institute for Healthcare Improvement, Mr. B

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