C489 RCA and FMEA (2.1).docx - Running Header Task 2 RCA and FMEA Organizational Systems and Quality Leadership C489 Constance White Western Governors

C489 RCA and FMEA (2.1).docx - Running Header Task 2 RCA...

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Running Header: Task 2 - RCA and FMEA 1 Organizational Systems and Quality Leadership - C489 Constance White Western Governors University
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Running Header: Task 2 - RCA and FMEA 2 A root cause analysis (RCA) is done as a ‘method of problem solving that helps to identify how and why an event occurred. RCA is defined by TJC (2013) as a “process for identifying the factors that underlie variation in performance. Including the occurrence or possible occurrence of a sentinel event. A root cause analysis focuses primarily on systems and processes, not individual performance.” (Cherry, Jacob, 2019, p. 380) According to IHI, the six steps used to conduct an RCA are: identify what happened, determine what should have happened, determine causes, develop causal statements, generate a list of recommended actions to prevent the occurrence of the event, write a summary and share it (Failure Mode and Effects Analysis, n.d.) In the given scenario the factors that occurred and added to the sentinel event include: not following conscious sedation policy (no ecg, no continuous monitoring following procedure). The LPN who turned off the initial alarm and rechecked a pulse only never reported to the RN who had the conscious sedation module training. Another RN should have been pulled as back up as the ER got busier. The patient should not have been left unattended by qualified staff.
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