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NURSING BS C489 / C 489 Task 2 Organizational Systems and Quality Leadership GRADED A+ $12.49   Add to cart

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NURSING BS C489 / C 489 Task 2 Organizational Systems and Quality Leadership GRADED A+

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NURSING BS C489 / C 489 Task 2 Organizational Systems and Quality Leadership GRADED A+

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  • February 15, 2022
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  • 2021/2022
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Organizational Systems Task 2 1




Organizational Systems and Quality Leadership

SAT Task 2

Jenny Juliana Mick

Western Governors University




05/31/2020

, Organizational Systems Task 2 2



Organizational Systems and Quality Leadership SAT Task 2

A. Root Cause Analysis

Root cause analysis or RCA is defined as a “systematic approach to understanding

the 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 to

focus on the system causes then to place blame on individuals.

A1. RCA Steps

A 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 the

RCA team can identify what happened. In this step the team will organize and clarify the event in

question 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

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