Running head: Organizational Systems Task 2 1 Organizational Systems and Quality Leadership SAT Task 2 Jessica Reed Western Governors University Updated: 2/1/19

Running head: Organizational Systems Task 2 2 Organizational Systems and Quality Leadership SAT Task 2 A. Root Cause Analysis The purpose of a root cause analysis is to look at an error in a systematic pattern to determine the cause of the event. It then identifies the issues that need correcting to prevent the event from happening again. (IHI, 2019c) A1. RCA Steps 1. Form a team- the team consist of 4-6 members of varied professions. Preferably these members have firsthand knowledge of the issues and process related to the adverse event. (IHI, 2019c) 2. Identify what happened- Preferably using a flowchart this step is used to determine what happened during the adverse event. This is a step by step process. (IHI, 2019c) 3. Determine what should have happened- Flow chart should be used again to determine what under perfect circumstances should have happened. 4. Determine what causes the error- the team now decides the factors that led to the error occuring preferably using a fishbone digram. Looking at “direct causes” most obvious and “contributory factors that are indirect in nature”. It is suggessted that the team “ask why five times” to get to the absoulte cause of the error. There are seven factors that effect affect errors they include “patient characteristics, task factors, individual staff members, team factors, work environmen, organizational and management factors, institutional context” (IHI, 2019c) 5. Develop a causal statement- This is a summary of the cause and effects of the incident. This statement creates a link from the causitive factors to the effects it has cuased and then back to the error itself. There are three pieces to the statemnt the cuase, the effect, and the event. (IHI, 2019c) Updated: 2/1/19

Running head: Organizational Systems Task 2 3 6. Generate a list of recommended actions to prevent the recurrence of the event- at this step the team presents the recommended changes that they purpose will prevent the event from happening again. This could includes strong actions, intermediate actions and weak actions. (IHI, 2019c) 7. Write a sumamry and share it- perferably in a flow chart this step is used to further the action plans that were suggested. A2. Causative and Contributing Factors First I would form the team that will perform the RCA. I suggest that a registered nurse who works the emergency room, the LPN, an emergency room physician, the emergency room nurse manager, and a representative from risk management consist of the team. Second determine what happened in this sentinel event. One RN one LPN and one MD were on staff. RT was available if needed on a prn status. There are a total of three patients in the department two are awaiting completion of their work up. It is determine that Mr. B needs a closed reduction. At 1605 Nurse administers diazepam 5mg IVP, five minutes later pt was not sedate enough hydromorphone 2mg IVP was ordered and administered at 1615. Patient still not