C489 _ CH Task 2.docx - Running head RCA AND FMEA Organizational Systems and Quality Leadership Task 2 Name Western Governors University RCA AND FMEA A

C489 _ CH Task 2.docx - Running head RCA AND FMEA...

This preview shows page 1 - 4 out of 12 pages.

Running head: RCA AND FMEA Organizational Systems and Quality Leadership Task 2 Name 6/15/2020 Western Governors University
Image of page 1
RCA AND FMEA A. General purpose of a Root Cause Analysis (RCA) Root cause analysis (RCA) is a methodology used to aid works in understanding the causes of an error and to help determine the faults that may be corrected in order to prevent such an error from occurring in the future (IHI, 2020). While the focus of this paper is within the healthcare industry and on the given scenario, RCA is also applicable in other fields. 1. Six Steps of an RCA There are six steps in RCA, as described by the Institute for Healthcare Improvement (IHI). They are described below. Step 1: Identify what has happened The first step in RCA is to identify the error or event. This is considered the information gathering stage, as without clearly recognizing the event that has taken place, subsequent correction steps are difficult. Here, the team must talk to those involved to draw a picture of what happened in the correct order (IHI, 2020). Step 2: Determine what should have happened The second step is to agree on the ideal outcomes that should have been produced. A visual or chronological set of ideal circumstances through the hospital policies, best practices, or medical literature would be created to compare the error to a preferred set of events (IHI, 2020). Step 3: Determine causes (“Ask why five times”) To understand how to prevent errors from occurring, the team must understand the facts that influenced an error. In this step, the obvious (direct) and the contributory (indirect) factors must be identified. Direct factors could include the medication being prescribed the way it was. Indirect factors may be related to staffing, education of the staff, or poor communication
Image of page 2
RCA AND FMEA amongst staff. By identifying this step as the “Ask why five times” step, a team may arrive at a core, or root, explanation for an error occurring. The use of a “fishbone diagram,” or another graphical tool may be used to help facilitate this step (IHI, 2020). Step 4: Develop Casual Statements A casual statement aids in explaining how the indirect factors contributed to the bad outcome for a patient or staff. In this step, linking “the cause”, “the effect”, and the “event” can allow easy linking of the error to the main event that initiated the RCA. It is important to recognize that these statements are not designed to place blame on a specific individual for the purpose of being reprimanded, but rather to understand the cause/effect items leading to an identified outcome (IHI, 2020). Step 5: Generate a list of recommended actions Specific to improving healthcare, this step are actions that can be used in the future to stop identical events from t occurring in the future. Such actions aim to address with an error’s root causes to varying depths and fall into several categories. Strong actions aim to eliminate the likelihood of an error being repeated while intermediate action is based in controlling the root causes. Categories for action could include standardization, building redundancy, staff
Image of page 3
Image of page 4

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture