Root Cause Analysis, Change Theory, FMEA, and Nursing Root Cause Analysis (RCA)

3214 words 13 pages
Show More
RUNNING HEAD: RTT1 TASK 2

1

RTT1 Task 2: Root Cause Analysis, Change Theory, FMEA, and Nursing Western Governors University

RTT1 TASK 2

2

RTT1 Task 2: Root Cause Analysis, Change Theory, FMEA, and Nursing Root Cause Analysis (RCA)
A root cause analysis (RCA) is an essential tool that can be used to examine and understand the ways in which systems fail as well as discuss those specific failures that led to a specific adverse event and potentially implement steps or behaviors to prevent that event from happening in the future (Ogrinc & Huber, 2013). In the case study presented, a number of system failures may have contributed to the patient outcome. As such, an RCA of the case study would help determine those specific …show more content…

Once the five “whys” have been addressed a clearer picture of the root cause of the event will manifest. In this case, it appears that a main causative factor could have been the lack of appropriate staff both for the monitoring of Mr. B and for the busy emergency department. As such, a revision of an existing policy or creation of a new policy that sets standards for staff matrices based on census be implemented. Another useful tool to use would be a fishbone diagram. In this case, Mr. B’s death could be used as the spine with contributory factors emerging along the spine to illustrate the factors contributing to the sentinel event. For example, lack of appropriate monitoring by ECG, silencing of the alarm by LPN, not notifying the RN of the alarm reading, distracted staff, lack of policy for calling in additional back up staff, over sedation, lack of appropriate chart review by MD, etc. can be used as contributing factors. According to Charles Vincent in an article titled, Framework for analyzing risk and safety in clinical medicine, there are seven factors that affect clinical practice and can be used as tools in the fishbone diagram or other objective analysis in this stage. They are patient characteristics, task factors, individual staff members, team factors, work environment, organizational and management factors

Related

  • Mr B Root Cause
    1744 words | 7 pages

    presenting with severe left leg pain at the emergency room. A root cause analysis is necessary to investigate the causative factors that led to the sentinel event. The errors or hazards in care in the Mr. B scenario will be identified. Change theory will be utilized to develop an appropriate improvement plan to decrease the likelihood of a reoccurrence of the outcome of the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA) will be used to project the likelihood that the suggested improvement….

    Show More
  • Sat Task 2
    3077 words | 13 pages

    A. Root Cause Analysis A root cause analysis (RCA) is 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” (Huber & Ogrinc, 2010). The root cause analysis is used to determine why the problem occurred in the first place and to identify the cause of a problem using a specific set of steps (Mind Tools, n.d.). The RCA team which consists of interprofessionals who are knowledgeable of the….

    Show More
  • Wgu Org Sys2Tems Paper 2
    4476 words | 18 pages

    a rural ED with left leg pain that he found unbearable. A root cause analysis will be used to exam the causative factors that led to this unfortunate sentinel event. Then I will identify the errors or hazards in the care of Mr. B. A change theory will then be utilized to establish a useful improvement plan that would hopefully decrease the chances of a repeat of the outcome in the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA) will then be….

    Show More
  • RTT Role of Organizations
    1202 words | 5 pages

    2 Organizational Systems This paper is the analysis of the avoidable sentinel event of Mr. B, a sixty-seven year old patient who was admitted to the emergency room with left leg and hip pain following a fall. A root cause analysis will help identify key elements which led to the unfortunate event. A plan of action to develop a change theory will help formulate an improvement plan to prevent future occurences like that of Mr. B. A failure….

    Show More

Popular Essays