C489 task 2.docx - Christina Scott C489 Organizational Systems and Quality Leadership SAT Task 2 RCA FMEA A Root Cause Analysis A root cause

C489 task 2.docx - Christina Scott C489 Organizational...

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Christina Scott C489 Organizational Systems and Quality Leadership SAT Task 2: RCA & FMEA
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A: Root Cause Analysis A root cause analysis (RCA) is a tool used to look back on an event that occurred to understand what might have caused this particular event. It is also used to identify missteps or breakdown leading to the event in order to correct the wrong actions and create a work flow to prevent future events from occurring. By making a chronological timeline of the steps leading to the adverse event, a healthcare system should be able to address the mix of active failures leading to the error with the hope of fixing the breakdown (IHI, n.d.). A1: RCA Steps The Institute for Healthcare Improvement (IHI) lists six steps to use when forming a RCA. The first step is forming a complete and accurate timeline of the event from start to finish by all staff members involved. One way to do this is to create a flowsheet providing further organization and clarity to the event. Determining how the situation should have played out in an ideal situation is the second step. Creation of a flowsheet for the ideal situation next to the flowsheet of what actually happened can show where any break downs in the system occurred. Step three assists in determining the cause of what happened. In this step, the team might ask the question” Why?” five times. The team can start to determine any factors contributing to the event by looking at direct causes and contributing factors. In step four, a causal statement is created which links the cause to the effects. This statement contains three components: the cause, the effect and event. Step five directs team members to form a list of suggested activities to avert future incidences of the same event. There are various categories the team for the team to use to create their list of actions to prevent recurrence. The final stage in the RCA is a written summary to be shared with the hospital and possibly other healthcare systems who could benefit from what was learned (IHI, n.d.).
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A2: Causative and Contributing Factors The team created for the RCA will have approximately four to six members’ form a group of mixed professionals in various levels within in the organization with knowledge of the issue under discussion and the processes involved in the incident. Clinical and administrative leader are used to support the RCA team. The RCA team will begin with step one where they will identify what happened. An organized flowsheet will follow much like how the scenario read. The team will start at the beginning where Mr. B was brought to the emergency department by his son and neighbor complaining of hip pain after a fall. The rest of the follow sheet will follow the events of all the things that happened while Mr. B was receiving care from triage to the reduction of his hip and the downward spiral leading to intubation, flight to a higher level of care hospital and his eventual death. This flowsheet will also state all staff and equipment available during Mr. B’s
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