4 - Organizational Systems - Task 2 Paper - RCA & Mr. B Scenario.docx - Running head TASK 2 1 Task 2 Western Governors University TASK 2 2 Task 2

4 - Organizational Systems - Task 2 Paper - RCA & Mr. B Scenario.docx

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Running head: TASK 2 1 Task 2 Western Governors University
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TASK 2 2 Task 2 Purpose of a Root Cause Analysis The purpose of conducting a root cause analysis (RCA) after an adverse event is to identify the latent conditions that led to the event with the intent of preventing the same or similar event from happening in the future (Ogrinc & Huber, 2018). RCA Steps The RCA process begins with the formation of a team of individuals who may or may not have been involved in the incident and consists of six steps: establish what happened in the event, determine what should have taken place, uncover causes, create causal statements, make a list of recommendations to prevent the event in the future, and summarize and communicate the information (Ogrinc & Huber, 2018). The first step is to establish what transpired at the time of the adverse event as completely and accurately as possible (Ogrinc & Huber, 2018). This is the information gathering phase. According to Ogrinc and Huber (2018), it is helpful to start with an initial account of the event then fill in gaps of information by reviewing documentation, observing staff workflows, and interviewing team members. The product of this step is a detailed map describing what happened leading up to the incident. Once the actual order of events is clear, the next step involves reviewing related policies and procedures and consulting the appropriate leaders to create another detailed map illustrating what should have happened (Ogrinc & Huber, 2018). Comparing the two maps to identify the differences can be used to hone in on contributing factors later in the RCA process (Ogrinc & Huber, 2018).
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TASK 2 3 Once the diagrams from steps one and two are completed and compared, causes of the adverse event can be identified. Ogrinc and Huber (2018) explain that it is important to consider not only the direct causes of the event, but also the contributing factors that are less apparent, to avoid addressing causes that are merely a manifestation of the root cause. This step can be completed by starting with an obvious direct cause of the adverse event then working backward by continuing to identify the factors that led to the direct cause until a root cause is uncovered (Ogrinc & Huber, 2018). Fishbone diagrams that organize identified causes into categories provide a visual display of the information being explored and can aid in identifying patterns that could also point to a root cause (Ogrinc & Huber, 2018). After a root cause is discovered, a causal statement can be made. These statements form the link between the root cause, contributing factors or a direct cause, and the adverse event. Causal statements are written using language that avoids judgmental connotation and will never include human error as a contributing factor (Ogrinc & Huber, 2018).
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  • Fall '17
  • TASK 2, Root cause analysis, Failure mode and effects analysis, RCA, Mr. B, Nurse J, C489, Mr. J Scenario, Mr. B Scenario

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