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Summary C489 Task 2. edited.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 The Institute for Healthcare Improvement (IHI) $7.49
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Summary C489 Task 2. edited.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 The Institute for Healthcare Improvement (IHI)
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C489 Task 2. 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 The Institute for Healthcare Improvement (IHI) has identified a Root Cause Analysis (RCA) as a systema...
c489 task 2 editeddocx c489 c489 organizational systems and quality leadership sat task 2 western governors university organizational systems and quality leadership sat task 2 a root cause an
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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
The Institute for Healthcare Improvement (IHI) has identified a Root Cause Analysis
(RCA) as a systematic approach to determine causative factors and identify system flaws that can
be corrected to prevent adverse events. (Institute for Healthcare Improvement, n.d.). The RCA is
a retrospective approach that focuses on system causes rather than blaming others by considering
all contributing factors within the work environment that led to the event. The focus is to identify
system flaws to prevent future adverse events. (Institute for Healthcare Improvement, n.d.).
A1. RCA Steps
The Root Cause Analysis team is from all organizational levels who have a fundamental
knowledge of the processes and issues involved in the adverse event and consists of 4 – 6 mixed
professionals. (Institute for Healthcare Improvement, n.d.). The RCA involves a six-step process.
Step 1 is collecting the data in an accurate, organized, and complete manner to draw a picture
such as a flowchart to determine what happened to cause the event. The data comes from staff
reports, incident reports, and medical record review. (Institute for Healthcare Improvement,
n.d.). Step 2 is to gather data to determine what should have happened or would have happened if
actions implemented by the staff and the hospital would have completed a proper system process.
By creating a flowchart with this data and comparing it with the chart from the first step, the
, team can determine the differences and where the problems may have occurred. (Institute for
Healthcare Improvement, n.d.). Step 3 is to determine the underlying causative factors by asking
“why” five times. The RCA team looks at the most likely or direct cause and the contributing or
indirect in nature cause to determine the underlying factors that lead to the adverse/sentinal
event. The contributing factors can include work environment, patient characteristics, and team
factors. (Institute for Healthcare Improvement, n.d.). A flowchart used for exploring and
identifying possible causes is the fishbone diagram, known as the cause and effect diagram.
(Institute for Healthcare Improvement, n.d.). Step 4 is to create a causal statement that reflects
the contributing factors the cause is linked to, as identified in step 3, to the undesirable outcome.
The causal statement consists of three separate parts: the cause or reason the event occurred, the
effect or what may have led to something else happening, and the event or what led to this
outcome. (Institute for Healthcare Improvement, n.d.). The causal statement is what links the
cause back to the adverse/sentinel event that led to the RCA. (Institute for Healthcare
Improvement, n.d.). Step 5 is to create a recommended list of changes in the system that would
prevent the event's future occurrence. Examples of changes include standardization of
equipment, developing new policies, checklists, simplifying processes, and educating the staff.
(Institute for Healthcare Improvement, n.d.). Step 6 is to improve the system process by
clarifying, organizing, and summarizing the data in the correct order it occurred to present it to
the organizational leaders and individuals involved in the unpleasant outcome. (Institute for
Healthcare Improvement, n.d.).
A2. Causative and Contributing Factors
After reviewing the listed scenario, it is apparent that Nurse J and DR. T did not follow
the facility’s moderate/analgesia conscious sedation policy concerning drug selection and
acceptable drug dose range. Per the facility’s policy, MR. B should have been monitored via
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