1Running Head: Organizational Systems and Quality Leadership Task 2Organizational Systems and Quality LeadershipTask 2Christina DavisWestern Governors University
2Task 2A. Root Cause AnalysisRoot Cause Analysis (RCA) is a tool that healthcare professionals use to identify situational problems such as medication errors, ineffective communication, or process errors. RCA helps healthcare professionals by enabling them to reflect on these situations, allowing them to see how these situations occurred, how they can be prevented, and what can be done differently next time.A1. RCA ProcessTypically, an RCA team consists of four to six people from a mix of different professionals (IHI 2019). There are six steps used to conduct RCA according to IHI. The first step in the RCA process is to Identify the issue or problem. The RCA team must be able to paint a complete and accurate picture of the event. The second step is to determine what the ideal outcomewould have been in this situation. Step three is to determine what caused the issue or problem. During this step it is recommended that you “ask why five times” to get an accurate underlying root cause. The fourth step is to develop a casual statement, this connects the cause to the effect. Inthis step the team explains contributory factors or conditions that resulted in the adverse event. In the fifth step the team would develop a list of interventions that can be done to decrease the likelihood of the event happening again. The final step in the RCA process is to summarize and organize all the data collected to compose a final report that is then reviewed by all who are participating in this process.A2. Causative and contributing factors
3Task 2The factors that resulted in the death of Mr. B based on the scenario, was the over administration of sedation medication, not utilizing the proper monitoring equipment to monitor Mr. B while under sedation, and not following Hospital protocol on moderate sedation. The ideal outcome would be that Mr. B had his hip procedure done successfully, while being monitored per hospital protocol, and being discharged to go home alive and well. Over sedation and inadequate monitoring led to the death of Mr. B. Mr. B’s death was caused by multiple doses of diazepam and hydromorphone. Mr. B was not placed on any supplemental O2. His ECG leads were not connected, and his respirations were not being monitored. The over sedation caused Mr. B to go into respiratory distress and then ultimately respiratory failure which caused brain death. There areseveral Interventions that could have been done to prevent Mr. B’s death. There should have been
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Root cause analysis, Failure mode and effects analysis, RCA