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Running head: Organizational Systems Task 21Organizational Systems and Quality LeadershipSAT Task 2Jolavon RomeroWestern Governors University
Running head: Organizational Systems Task 22Organizational Systems and Quality Leadership SAT Task 2A. Root Cause AnalysisThe purpose of conducting a root cause analysis is to determine the cause of an adverse event and identify system flaws that can be corrected to prevent more adverse events from occurring. It is looking back at an incident that occurred. The purpose is not to point blame to an individual involved in the adverse event. An RCA team typically has 4-6 members from different levels in the organization. A1. RCA StepsThe IHI has six steps to complete an RCA. The first step is to identify what happened accurately and completely in a timeline step by step. Step two is to identify what should have happened in the ideal conditions. Determining the causes directly or indirectly is step three. Oneway to do this is by asking why five times. A second way is to create a fishbone diagram. Step four is to develop a causal statement which links the cause to the effect and then back to the event that caused an RCA to be performed. When a causal statement is developed, we can determine what indirect factors contributed to the bad outcome for patients or staff. In step five alist of recommendations is developed to prevent the event from occurring again. There are nine categories of recommendations: standardizing equipment, safeguarding redundancy, using forcing functions to physically prevent the user from making a mistake, changing the physical plant, updating or improving software, use cognitive aides like checklists or labels, simplifying a process, educating staff and developing new policies. The last step in the RCA process is to summarize the information and share it.
Running head: Organizational Systems Task 23A2. Causative and Contributing FactorsA 67-year-old patient, Mr. B, arrived at the emergency department with a dislocated hip and received conscious sedation in which he went in to cardiopulmonary arrest and eventually passed after determining brain death and life support was removed. This is the first step in identifying what happened. A flowchart could be presented with a sticky note indicating each step that took place. The second step is to determine what should have happened. In this scenario, more time should have been allowed to obtain the full effect of the medications prior to administering the next dose. The policy states the patient should be on continuous cardiac monitoring, blood pressure and pulse oximeter throughout the procedure and this was not performed until the procedure was completed. The respirations were not being monitored at all.