Running head: Organizational Systems Task 2
1
Organizational Systems and Quality Leadership
SAT Task 2 RCA/FMEA
Lori A. Di Betta
Western Governors University
Updated: 2/1/19
Running head: Organizational Systems Task 2
2
Organizational Systems and Quality Leadership SAT Task 2
A. Root Cause Analysis
The general idea of conducting a root cause analysis is to learn from errors by using a
systematic approach to figure out the causes of an adverse event, and identifying defects in the
system that can be fixed to prevent the error from happening again.
A1. RCA Steps
Step 1: Identify what happened
Step 2: Determine what should have happened.
Step 3: Determine causes (“ask why five times”).
Step 4: Develop causal statements.
Step 5: Generate a list of actions to prevent the recurrence of the event.
Step 6: Share the findings.
A2. Causative and Contributing Factors
Step 1: What Happened
Presentation:
67 yo male with hx of impaired glucose intolerance, prostate cancer, hypercholesteremia and
hyperlipidemia, chronic back pain, opioid (oxycodone) use, presents to ED complaining of
severe pain in L leg and hip. Had a fall after tripping over dog. BP 120/80, HR 88, RR 32
On Admission:
Admit to regular ED from Triage.
L leg appears shortened with edema in the calf, ecchymotic and limited ROM.
ED Course:
1605 5 mg IV Diazepam. Not effective.
Updated: 2/1/19
Running head: Organizational Systems Task 2
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1615 2 mg IV Hydromorphone. Not effective
1620 5 mg IV Diazepam, 2 mg Hydromorphone
1625 Pt sedated, Hip reduction takes place.
1630 Pt resting comfortably. Pt placed on automatic BP and pulse oximetry to go off
every 5 minutes.
1635 BP 110/62, O
92%. ECG and respirations not monitored. No supplemental oxygen
₂
given.
1640 O
found to be 85% after oximeter alarms. Alarm reset by LPN
₂
1643 Pt BP 58/30, O
saturation 79%, no respirations, no palpable pulse
₂
Code is called. Resuscitation begins after code team arrives. Pt in Vfib. RN begins CPR,
Pt intubated. Defibrillated, given reversal agents, IV fluids and vasopressors.
After 30 minutes of intervention NSR regained, pulse evident, BP 110/70. Pupils dilated
and fixed, pt dependent on vent. No spontaneous movements, no response to noxious
stimuli.
Pt transported to tertiary facility for advanced care, found to be brain dead, removed from
life support.
Step 2: What Should Have Happened
Additional, available staff should have been called in when census increased
BP and pulse ox should have been on continuously
ECG and Respirations should have been monitored
Low O
saturation should have been assessed and addressed
₂
Clinical status should have been reassessed following clinical change (drop in O
₂
saturation)
Updated: 2/1/19
Running head: Organizational Systems Task 2
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Notification of RN should have happened after pulse oximetry alarm was reset
CPR should have begun prior to arrival of code team
All employees working in ED should have ACLS (inferred that LPN did not have ACLS)
Step 3: Causes
Staffing policies were not in place to address census issues, or policies were not followed.
