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Summary c489 task 2.docx C489 Organizational Systems and Quality Leadership SAT Task 2 College of Health Professions, Western Governors University January 27th, 2021 Organizational Systems and Quality Leadership SAT Task 2 A. Root Cause Analysis In 1996,$4.99
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Summary c489 task 2.docx C489 Organizational Systems and Quality Leadership SAT Task 2 College of Health Professions, Western Governors University January 27th, 2021 Organizational Systems and Quality Leadership SAT Task 2 A. Root Cause Analysis In 1996,
c489 task C489 Organizational Systems and Quality Leadership SAT Task 2 College of Health Professions, Western Governors University January 27th, 2021 Organizational Systems and Quality Leadership SAT Task 2 A. Root Cause Analysis In 1996, the Joint Commission adopted a sentinel event pol...
c489 task 2docx c489 organizational systems and quality leadership sat task 2 college of health professions
western governors university january 27th
2021 organizational systems and quality le
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C489 Organizational Systems and Quality Leadership
SAT Task 2
College of Health Professions, Western Governors University
January 27th, 2021
, 2
Organizational Systems and Quality Leadership SAT Task 2
A. Root Cause Analysis
In 1996, the Joint Commission adopted a sentinel event policy which requires accredited
organizations to perform a Root Cause Analysis (RCA) after a sentinel event occurs. An RCA is
a systematic approach used to analyze serious adverse events and to identify both active and
latent errors. The general purpose of conducting an RCA is to identify the cause of a serious
event by looking the sequence of events that lead to the error and prevent future occurrences of
the event by establishing a process to prevent the errors that lead up to the sentinel event (PSNet,
2019). This process takes the blame off an individual and looks at system barriers that
contributed to the event.
A1. RCA Steps
An RCA team generally consists of 4-6 team members of individuals at all levels of an
organization who have knowledge of the event and the issues and processes involved (Institute
for Healthcare Improvement, n.d.). In this scenario, the team would consist of the ED physician,
the RN, the LPN, the Respiratory Therapist, the risk manager, and the patient safety
representative. The Institute for Healthcare Improvement (IHI) recommends using a 6-step
process for conducting an RCA. The first step of an RCA is identifying what happened by
describing what happened with accurate and complete details. The next step is for the team to
determine what should have happened. The third step is to determine the causes of the event.
The IHI recommends asking “why” questions in order to get to the underlying or “root” causes.
Step 4 involves the development of causal statements. A causal statement links the cause to its
effects and how they relate to the event. It is composed of three parts: the cause, the effect and
the event. Step 5 is for the team to collaborate and generate a list of recommended actions that
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