Task 2.docx Running head: Organizational Systems Task 2 1 Task 2 Organizational Systems and Quality Leadership SAT Task 2 Western Governo
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Task 2.docx Running head: Organizational Systems Task 2 1 Task 2 Organizational Systems and Quality Leadership SAT Task 2 Western Governors University Organizational Systems and Quality Leadership SAT Task 2 A. Root Cause Analysis When an error occurs in healthcare, a team of four to six people come together to try and figure out what caused the event and find defects in the system. The group tries to understand what happened in hopes of preventing it from happening in the future. This is called a root cause analysis and rather than focus on blame, it focuses on what caused the event. A root cause analysis is not suitable if the event is caused by negligence or willful harm. A1. RCA Steps When conducting a root cause analysis, the RCA team uses six steps to complete the process. Step 1 is figuring out what exactly happened. Flowcharts are commonly used to organize the findings. Next, the team determines what should have actually occurred if the conditions were ideal. Again, a flowchart is made and then compared to the flowchart in step 1. In step 3, the team looks at direct and indirect causes. It is advised that they "ask why five times" to get to the root cause. Using a fishbone diagram allows them to recognize and group factors together. The team begins to create a three-part causal statement in Step 4. These link the cause from step 3 to the effects, which then is linked back to the main event. Af. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. . . . . . . . . . . . . . . . . . .. . . . .
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