Running Head: Task 2C489 Organizational Systems and Quality Leadership - Task 2Western Governors University1
Task 2A. The main justification for doing an investigation of the root cause is to solve a problem. You need to be able to identify what the problem(s) are, and what the causes are to solve a problem. The main purpose of using RCA (Root Cause Analysis) is to determine what has occurred, how it has happened, and why. Conducting an RCA helps the investigator locate the source from which the problem originates, thus enabling them to solve the problem, and helps put in place measures to prevent the problem from occurring again in the future.A1. Explain each of the six steps used to conduct an RCA, as defined by IHI.Step one in using an RCA is to identify what happened. The data must be as accurate as possible and as detailed as possible. You may construct a flowchart to help in visualizing the process and clarifying the order of events. You are discovering the truth in that step of the process. To be correct, you need to check the incident report and the medical chart of the patient. The information collection shouldn't be done by the people involved in the incident.Step two is deciding what ought to have happened. The team members will have to decide in "ideal conditions" what should have happened. Also, a flowsheet in this step could be useful in comparing it to the flowsheet one generated in the first step.Step three is stating, "Why?" five times to determine the cause. This is where the team looks at and decides factors that contributed to the incident. This involves both the most apparentreasons and indirect ones. With this step, a fishbone diagram could be useful for exploring and showing the possible causes of a particular effect.Step four is to develop causal statements that connect the cause to the effect, and then 2
Task 2return to the central incident, which was the RCA's reason. By making causal statements, we provide a basis for how the responsible factors help with wrong outcomes for patients and staff. Acausal statement has three separate parts, including cause, effect, and event.Step 5 is to create a list of ideas that could prevent this occurrence from happening again in the future. This list could include things such as policy standardization, consistency in a system to ensure compliance and the use of checklists, and process simplification. A team member should create a timeline for assessing the effectiveness of the policy change, and adjustments should be made when necessary.Phase six is to write and post a summary. Explanation of the process and how the occurrence occurred can help to avoid future errors. Hopefully, adverse effects would be minimized by spreading the results hospital-wide, which will increase patient satisfaction and raise employee morale.
You've reached the end of your free preview.
Want to read all 11 pages?
- Spring '19
- Nursing, Failure mode and effects analysis, RCA, Twelve-step program, Nurse J