Organizational Systems Task 2
Organizational Systems and Quality Leadership
SAT Task 2
Organizational Systems and Quality Leadership SAT Task 2
A. Root Cause Analysis
Root cause analysis (RCA) is a system used to examine adverse effects from health care practices (AHRQ, 2019). The general purpose of conducting a root cause analysis is To dissect the errors made to find the underlying issue that could prevent the same mistake from happening again. RCA focuses on the event rather than just the individual making it a systems approach, where the issues of human error and care systems both contribute to the event. This can be better explained by the Swiss cheese model, where the systems gaps or latent errors multiply they soon intersect causing an adverse event to breach patient safety (AHRQ, 2019).
A1. RCA Steps
The six steps used to conduct an RCA as defined by IHI are as follows, (IHI, 2019).
1. Identify What Happened
In order to organize correct data the group involved needs to descrive in detail what exactly happened in its entirety to gather the full picture.
2. Determine What Should Have Happened
If the world had zero flaws the group must collaborate on what the ideal scenario shoul have been. IHI recommends using a flow chart to organize data and compare to the actual scenario.
3. Determine the Cause
This is the step where the factors are identified whether they are direct and obvious and also indirect such as a system flaw. It is recommended to ask why five time to find the root cause and also organize the data on a fishbone diagram. There are seven major factors that can relate to medical errors including, patient characteristics, task factors, individual staff member, team factors, work environment, organizational and management factors and institutional context. All of these must be recalled to find the root cause of the scenario.
4. Develop Causal Statements
Casual statements are developed by, taking the cause, which was identified in step three, and then recalling the effect and then stating the event from the scenario. This is how to explain the contributory factors in a basic statement to understand the full picture.
5. Generate a List of Recommended Actions to Prevent Recurrence of the Event
The list will include any act that the group believes will help to prevent this error from reoccurring. Examples such as equipment, improving software, staff education, new policies and so forth.
6. Write a Summary and Share it
The last step in forming a root cause analysis is to document it in a way to engage the team and motivate them to take the steps for improvement.
A2. Causative and Contributing Factors
Using the RCA process in this scenario these are the factors that led to the sentinel event outcome of Mr. B passing away. To main cause of death was due to over sedation causing his body to go into cardiopulmonary arrest. Mr. B was given diazepam and hydromorphone with in a 15 minute time period. Though they wer...
