c489 task 2.docx - SAT Task 2 RCA and FMEA 1 Organizational Systems and Quality Leadership Task 2 RCA and FMEA Western Governor\u2019s University Victoria

c489 task 2.docx - SAT Task 2 RCA and FMEA 1 Organizational...

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SAT Task 2 RCA and FMEA 1 Organizational Systems and Quality Leadership Task 2 RCA and FMEA Western Governor’s University Victoria Helman
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SAT Task 2 RCA and FMEA 2 A. Root Cause Analysis A root cause analysis (RCA) is essentially a method used to look back at a particularly negative event and to identify flaws or factors that contributed to this event that can be adjusted for future prevention. In the healthcare system it can be easy to put blame on a person for an event going wrong, however that does nothing to help prevent further incidences. Focusing on a cause instead of placing blame is fundamental to a root cause analysis. Overall, an RCA breaks down an event or chain of events and focuses on what happened or what went wrong, how did we get this adverse outcome, and how can we prevent it from happening again? (Institute for Healthcare Improvement, n.d.) A1. RCA Steps The steps of an RCA are the following: 1- Identify what happened. Sit down with the team/group of individuals and discuss exactly what happened. Discuss chain of events, results, etc. 2-Determine what should have occurred. Reflecting back on the events, it is often easy to see what should have happened in a ‘perfect world’ with ideal conditions. The team can identify what the ideal patient interventions and outcomes would have been. Some groups may make a chart for step 1 and step 2 and compare the results. 3-Determine causes. I feel that this step is where it may be the easiest or as humans, more prone to place blame. But, the team has to look at the overall event and ask “WHY” at least five
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SAT Task 2 RCA and FMEA 3 times. Asking why helps to pinpoint direct causes and any contributing factors. (Institute for Healthcare Improvement, n.d.) 4-Develop casual statements. Casual statements help to link a cause with the effect to the event/ negative outcome. These statements essentially explain how these contributing factors led to poor outcomes. 5- Generate list of actions to prevent recurrence. Developing a list of recommendations can help prevent further incidents by giving specific instructions to help reduce error and control situations more appropriately. 6- Lastly, write a summary and share. As stated before, some groups choose to implement flowcharts in this step. Creating a chart or summary easily lays out the events and clarifies information. Doing so can provide a better opportunity for implementing improvement steps. A2. Causative and Contributing Factors 1- Patient Mr. B was admitted to the Emergency Department (ED), assessed, and sedated so the physician could perform manipulation, relocation, and alignment of Mr. B’s left hip. Following the procedure Mr. B was left on a continuous pulse oximetry and serial blood pressure reading every five minutes, neither cardiac monitoring or supplemental oxygen were applied.
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