SAT TASK 2 RCA AND FMEA.docx - Western Governor\u2019s University Lemere Foster SAT TASK 2 RCA AND FMEA A The general purpose of conducting a root cause

SAT TASK 2 RCA AND FMEA.docx - Western Governoru2019s...

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Western Governor’s University Lemere Foster March 16, 2020 SAT TASK 2: RCA AND FMEA A. The general purpose of conducting a root cause analysis (RCA) is to learn how and why an error occurred. RCA process is used by health professionals, and should be a standardized process, and should improve the way medical errors, near misses, and adverse events are investigated. RCA process is non- punitive, and puts the focus on the system, instead of the person, however, it is not useful in cases of negligence or willful harm. RCA should be used to correct a current process to prevent future harm to patients. RCA answers four questions, what happened, why did it happen, what action can be taken to prevent reoccurrence, and how will we measure the outcomes of the new action. A1. According to Institute for Healthcare Improvement (IHI), there are six steps used to conduct an RCA: 1. The team will accurately and completely describe what happened 2. The team describes what would have happened under ideal conditions 3. The team determines what contributed to the event 4. Develop causal statements that relate the cause, the effect, and the event 5. The team creates a list of actions that they think will prevent this event in the future 6. The team writes a summary and shares it A2. In using the RCA process, I have identified causative and contributing factors that led to the sentinel event outcome in this scenario. A 67 year old male presented to the ED in severe leg and hip pain after a fall. The patient was assessed by the RN on duty, vital signs were taken, and a past medical history was provided by the patient. The nurse provided the on-duty physician with assessment findings. The physician proceeded to fix the patient’s hip, with orders given to the RN for necessary medications for the procedure. The patient received 10 mg of diazepam and 4 mg of hydromorphone IVP before desired pain control and sedation was achieved. The procedure was successful, and the patient was placed on automatic blood pressure and pulse ox monitoring. The RN then left the patient with his son and left to go check on another patient. The LPN working with the RN for the day, reset an O2 alarm in this patient’s room and left the room again. Later, the patient’s son alerts the staff that another alarm is sounding, when the RN
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