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Running Head: C489 TASK 2RCA and FMEATrey GilbertTask 2WGU
Running Head: C489 TASK 2A. A root cause analysis (RCA) is systemic process identifying “root causes” of problems or events and an approach for responding to them. Healthcare uses RCA’s to figure out what happened, and why it happened. And, to prevent it from happening again (Institute for Healthcare Improvement, 2004).A. A1. A root cause analysis has six steps. The six steps are as follows: (1) Identify what happened. During the analysis, the healthcare team can identify the problem, collect data, and use the information to create a flowchart showing what happened in the order it occured. (2) Identify “what should have happened.” The team should The team identifies what would have happend in an ideal situation. A flow chart is created and compared to the flowchart from step one. (3) Determine causes. In the third step the team determines factors that contributed to the event. To get at the un-derlying cause, many teams “ask why five times.” This is step is the “heart of the RCA.” A useful tool is a fishbone diagram, or “cause and effect” diagram, a graphic tool used to display possible causes. (4) Developing casual statements. Causal links explain how contributing factors contribute to poor patient and staff outcomes. (5) Generate a list of recommended actions to prevent the recurrence of the event. These are changes the team thinks can prevent the error in the future. (6) Write a summary and share it. This last step involves making a report and pre-sentation that includes what happened, the root cause, contributing factors and the recommendations.
A2. 1.Mr B. had ongoing oxygen saturation and blood pressure monitoring. An O2 alarm went off in the room. The LPN entered the room and reset the alarm. However, the patients 02 sat was at 85%, and yet the LPN did not report it to a RN or MD.