C489 Task 3 1 Organizational Systems and Quality Leadership C489 Task 3: RCA and FMEA Andrea Davis Western Governors University March 9, 2020
C489 Task 3 2 A. Root Cause Analysis: A root cause analysis (RCA) is a problem solving approach performed to determine the cause of a sentinel event. The information and findings from a root cause analysis allows for a healthcare team to determine and develop ways to prevent the sentinel event from occuring again. The Joint Commision requires all healthcare organizations which are accredited through them to perform a root cause analysis for any sentinel events that take place. A1. Six Steps of RCA Once a team of individuals is assembled to perform a root cause analysis, the first step is to determine what happened. This step includes gathering information including incident reports, walkthroughs of the facility/area where the incident occured, looking at equipment manuals and equipment, interviewing staff and individuals involved in the incident, and creating tools like flowcharts and diagrams of the facts and events that took place. The better the investigation and information that is obtained, the better the outcomes can be for the RCA. The second step is to determine what should have happened. In this step the team explores what should have happened to prevent this event. The third step is to determine causes. In this step, the team asks why five times. This allows them to dig deep into the real cause(s). The fourth step is to develop causal statements. Causal statements link the causative factors to the effect and back to the event. There are three parts to a causal statement- the cause, effect, and event. The fifth step is for the team to develop a list of actions that can prevent the event from recurring. The sixth step is to write a summary of the RCA and share it with the entire healthcare team. A2. Causative and Contributing Factors:
C489 Task 3 3 There were many causative and contributing factors in this sentinel event. There was inadequate monitoring of a patient under sedation. The nurse neglected to put supplemental oxygen on the patient while being sedated. The nurse did not implement any actions to improve the patient’s oxygen level once she noticed it at 85% on room air. The emergency department was understaffed, even though there was other staff available to work. The patient was left with a family member instead of a healthcare team member that is trained to recognize problems that may arise with a patient under sedation.
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- Fall '19
- Causality, RCA