Running head: RCA AND FMEA TASK 2 1 RCA and FMEA Task 2 Brandy Karcher WGU Organizational Systems and Quality Leadership C489
RCA AND FMEA TASK 2 2 Table of Contents References ........................................................................................................................................ 9
RCA AND FMEA TASK 2 3 RCA and FMEA Task 2 A. The general purpose of conducting root cause analysis (RCA) The general purpose of conducting a root cause analysis (RCA) is to find the why, or system failure, after an error or event occurs. A1. Explain each of the Six steps used to conduct and RCA, as defined by IHI There are six steps used to conduct an RCA as defined by the Institute for Healthcare Improvement (IHI). Step 1: Find out what happened. An RCA team is composed of leaders within the organization. The patient, nor staff directly involved with the case are included in the RCA team ("Going beyond," 2017). The team must come together and discuss step by step what happened in the scenario. Step 2: The RCA team carefully goes through the case to determine how things would have been different in ideal situations ("Patient Safety 104," n.d.). Often times, it is helpful to begin creating a chart to show the steps of what happened versus the steps that should have happened for comparison ("Patient Safety 104," n.d.). Step 3: In this step you begin to ask why. The team starts looking at the agents that compiled together to cause the event ("Patient Safety 104," n.d.) According to the IHI, this is where the team would start to ask why five times ("Going beyond," 2017). Step 4: In this step “casual statements” ("Going beyond," 2017) begin to develop. The statement contains three main ideas; the root, the outcome, and the incident itself ("Going beyond," 2017). Step 5: In this step the team comes together to develop ideas of how to prevent the incident from occurring again ("Going beyond," 2017).
RCA AND FMEA TASK 2 4 Step 6: In the final step, a written conclusion is submitted to the decision makers to make improvements in processes to prevent any future occurrences ("Going beyond," 2017). A2. Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome. There were many causative factors leading up to the sentinel event. The patient arrives to the rural ED with complaints of pain secondary to a fall at home. The patient is found to have a shortened left leg with limited range of motion. The patient states his pain is 10/10. The patient has a medication history of Oxycodone use, but there is not documentation as to when the last dose of Oxycodone was taken. The provider evaluates the patient and prepares for conscious sedation to reduce the hip, ordering a narcotic and benzodiazepine. Respiratory therapy is in house; however, never consulted to the room for conscious sedation. The patient was given multiple doses of medications in a very short period of time without being placed on supplemental oxygen or cardiac monitoring. The hospital has a conscious sedation policy that
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- Fall '17
- Failure mode and effects analysis, RCA