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Summary C489 task 2.docx C489 C489 Organizational Systems and Quality Leadership SAT Task 2 Western Governors University Organizational Systems and Quality Leadership SAT Task 2 A. Root Cause Analysis Accidents in health care often do not stem from one si
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C489 task C489 C489 Organizational Systems and Quality Leadership SAT Task 2 Western Governors University Organizational Systems and Quality Leadership SAT Task 2 A. Root Cause Analysis Accidents in health care often do not stem from one single factor, often it is affected by multiple cont...
c489 task 2docx c489 c489 organizational systems and quality leadership sat task 2 western governors university organizational systems and quality leadership sat task 2 a root cause analysis
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C489
C489 Organizational Systems and Quality Leadership
SAT Task 2
Western Governors University
Organizational Systems and Quality Leadership SAT Task 2
A. Root Cause Analysis
Accidents in health care often do not stem from one single factor, often it is affected by
multiple contributing factors, and to find the systemic cause of the error, one can use Root Cause
Analysis (RCA). RCA systematically assesses the causes of adverse events and identifies any
errors that can be corrected so it doesn't happen again. Generally there is a team of four to six
people from mixed discipline set up to do this.
A1. RCA Steps:
There are six steps in the process of RCA
1. Identify what happened
The first step is to identify where an error happened and describe it accurately. All
pertinent information about the event is gathered and organized in the order it took place
2. Determine what should have happened
Step two helps figure out what would have happened in an ideal situation. The team
creates a flow chart to compare step 1 and step 2.
3. Determine causes
After comparing the two steps, then the cause of the event is determined. What
contributing factors led to the error? Per the Institute of Healthcare Improvement, experts
, recommend that team ask “Why?” five times to figure out the root cause. They believe
that if you ask why enough times, the closer you get to finding out the cause. Team can
also use tools like fishbone diagrams to display possible causes of certain effects (IHI,
n.d).
4. Develop causal statements
This is where they team pieces together all the information gathered in steps 1-3 and figure
out how each contributing factor led to its effects and how that overall resulted in the main
event. A casual statement has 3 parts: the cause, the effect and the outcome (“How this
happened...and led to something else---which causes this undesirable outcome”)(IHI, n.d.).
5. Generate a list of recommended actions to prevent the recurrence of the event
The team then recommends remedies like standardized equipment, software
improvements, educating staff, new policies, cognitive aids, simplifying process,
ensuring redundancy, and few more that helps prevent future recurrence of the same
event. Not all actions are equally effective, hence can be labeled as strong,
intermediate or weak per the National Center for Patient Safety definitions.
6. Write a summary and share it
Final step in this process helps summarize the process of RCA and share the findings
of the process then further initiate solutions or recommended actions.
A2. Causative and Contributing Factors
In this scenario, the cascade of undesired events led to the unfortunate death of Mr. B. who
had come to the ER for a dislocated left hip after sustaining a fall at home.
Gathering information in Step 1 is very crucial to figuring out the causative and contributing
factors of the event. One of the major causative factors that led to the death of Mr. B. was
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