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1Running head: C489 TASK TWOTask 2 C489Tammy CosbyWestern Governors UniversityDecember 20, 2018
2Running head: C489 TASK TWOA: Root Cause AnalysisTo explain the general purpose for conducting a root cause analysis (RCA), one must firstunderstand what a root cause is. Two Medical Doctors by the name of Ogrinc & Huber (2010) state, “A root cause is a latent vulnerability in a system that allows an error to occur; changing or correcting the root cause could help prevent the error from happening again” (p.4). RCA is a systemic approach, meaning the use of the most efficient means to generate optimum results. Therefore, a root cause analysis helps one to understand the cause of an error by looking at the flaws that can be corrected with hopes to prevent the error from happening again. A1:RCA StepsAlthough each RCA has its own unique situation, there are six steps that are generally used to conduct an RCA and are listed below. These steps are conducted by a team of at least four individuals with various involvement with the incident. Step 1:Identify what happened by gathering information. A description of what happened needs to be as accurate and thorough as possible with the ultimate goal of improvement being at the forefront. The RCA team can gather this information by examining areas involved in the event, conducting interviews with staff or family members involved and reviewing incident reports that might have come from the event. Identifying what happened rather than why it happened is essential for honesty and trust from those being interviewed. Neutral, open-ended questions should be asked during this step which allows for a blame free process. Flowcharts are a good tool used in this step and allows one to look at the
3Running head: C489 TASK TWOincident methodically and review the steps for any particular situation in an unbiased manner (Ogrinc & Huber, 2010, p 7-8).Step 2: Determine what should have happened. Step two in the RCA process focuses on what would have happened if everything would have gone perfectly and a good outcome was maintained. Hospital policies and procedures could be analyzed, sifting through medical literature and interviewing department directors are tools that can be used to find out barriers to safe practice. Another flowchart is created showing what should have occurred if compliable procedures would have been followed. The flowchart are then compared to see what the ideal process is and the process that led to the adverse event to narrow down contributing factors later in the process (Ogrinc & Huber, 2010, p. 9).Step 3: Determine causes.This step is at the heart of the RCA process. In this step factors that led to the event are determined and improvement projects and strategies are put into place. Direct causes and contributory factors are identified in this step. Direct causes are the most apparent or immediate reason for the adverse event, whereas contributory factors are more indirect and are the ones that need focus. Determining the causes or contributing factors is different for each case. However,

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