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Organizational Systems Task 21Organizational Systems and Quality LeadershipSAT Task 2Jenny Juliana MickWestern Governors University05/31/2020
Organizational Systems Task 22Organizational Systems and Quality Leadership SAT Task 2A. Root Cause AnalysisRoot cause analysis or RCA is defined as a “systematic approach to understandingthe causes of an adverse event and identifying system flaws that can be corrected to prevent the error from happening again (IHI).” A root cause analysis evaluates the past actions of an event to learn and grow from the adverse error/harm caused to a patient. Typically, in a RCA, you want tofocus on the system causes then to place blame on individuals. A1. RCA StepsA root cause analysis is comprised of a total of six steps that needs to be followed.The first step is to identify how the event occurred and portray the event in its entirety so that theRCA team can identify what happened. In this step the team will organize and clarify the event inquestion and can create a flowchart to depict the order of events. Step two of an RCA, the team will put together the events in conditions that are ideal to determine what should have happened. The team will put together an “ideal” flowchart to compare it to the data/flowchart from step 1. In step three, the team will ask the why to the causes of the events. This is where the team establishes the factors that contributed to the event in question. Potentially, the team should ask the why five times to get to underlying or root cause of the event. Step four, the team explains the contributory factors in a causal statement that links the cause and effect back to the main event. Step five, the team creates a list of recommended actions or changes that can prevent the recurrence of the sentinel event in future practice. In this step recommendations often fall in categories or actions to generate these changes. Step six, the team can summarize the steps of improvement and implement these changes. The team can then disseminate the information to the hospital for future changes. 05/31/2020
Organizational Systems Task 23A2. Causative and Contributing FactorsApplying root cause analysis can help identify contributing factors leading up to the sentinel event involving Mr. B who was a 67-year-old patient that entered the emergency department for a trip and fall. Starting with step one of a RCA, the team would conclude that Mr.B was a patient of a rural 6 bed hospital for a dislocated hip after a fall. The physician on duty gave orders to the registered nurse to administer medication, that in combination, would produce a sedating effect on the patient. This sedating effect of the medication would place the patient in a position to have the physician preform a procedure, called a reduction, to manipulate the hip back into place. Per the hospital policy, to perform a conscious sedation the patient is required to have continuous blood pressure, ECG, and pulse oximeter throughout the procedure and the patient received none of these during the procedure. It is also identified that the patient was only