C489 Task 2 submission.docx - C489 Task 2 Organizational...

C489 Task 2 1
Organizational Systems and Quality Leadership
SAT Task 2
Maxine Silberman, student #950908
Western Governors University
May 12, 2020

C489 Task 2 2
A. Root Cause Analysis
The purpose of conducting a root cause analysis is to look back at an error which
occurred, determine the direct and contributing factors to the error, and identify the flaws in a
system that can be corrected to prevent this error from occurring in the future. A mix of different
professionals from all levels of the organization comprises the team conducting the RCA. (IHI
2019, Patient Safety 104).
A1. RCA Steps
The steps to performing a root cause analysis are as follows:
1. Identify what error occurred, in the order of occurrence.
2. In ideal conditions; determine what should have happened, comparing this
information to what actually occurred.
3. Determine the cause of the error occurrence by asking why, to find underlying or root
causes. Contributing causes as well as directly apparent causes are explored by the
team of professionals; who will explore the task factors, organizational and
management factors, patient characteristics, the staff members involved, the work
environment, and the team factors.
4. A causal statement is developed to explain how the facts of the conditions contributed
to the error. This should attempt to link the causes from step 3 to the error event
which prompted an RCA.
5. A list of recommended actions to take is developed by the team, in an effort to
prevent the recurrence of this same error in the future. If the actions taken are strong,
it is likely to eliminate or greatly reduce the occurrence of the same error. Conversely,

C489 Task 2 3
if the actions are weak they are less likely to be effective in preventing this error
occurrence.
6. A summary is written to help drive steps of improvement, and shared with key
players of implementation. (IHI, 2019, Patient Safety 104).
A2. Causative and Contributing Factors
In the scenario presented involving Mr. B. and his course of decline once arriving in the
ED, and having undergone reduction of his left hip under conscious sedation; the following error
occurred:
Additional medication was given to Mr. B. in order to achieve a satisfactory level of
sedation, as determined by Dr. T. Following the procedure blood pressure and O2 saturation are
being monitored, ECG and respiratory rate are not monitored, nor is supplemental oxygen in
place. Upon entering Mr. B’s room to respond to a monitor alarm, the LPN observes an O2
saturation level of 85%. Upon responding to the alert from Mr. B’s son regarding the monitor
alarm at a later time (after the LPN had entered to reset the blood pressure monitor); Nurse J
finds Mr. B. in a decompensated state of lowered blood pressure and O2 saturation, decreased
level of consciousness, and also finds no palpable pulse nor spontaneous respiration. At this time,
a STAT CODE is called and the code team begins resuscitative efforts. After 30 minutes of
intervention by the code team, Mr. B. returns to a stable cardiac rhythm and blood pressure, and
remains intubated with fixed dilated pupils. He is transferred at the family’s request to another