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C489 Task 2 Organizational Systems & Quality Leadership C489 Task 2 Organizational Syst

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C489 Task 2 Organizational Systems & Quality Leadership C489 Task 2 Organizational Systems & Quality Leadership C489 Task 2; SAT1-1217 Western Governors University A: ROOT CAUSE ANALYSIS (RCA) The purpose of a roo ...

C489 Task 2 Organizational Systems & Quality Leadership C489 Task 2 Organizational Systems & Quality Leadership C489 Task 2; SAT1-1217 Western Governors University A: ROOT CAUSE ANALYSIS (RCA) The purpose of a root cause analysis is to understand the causes of an adverse event and identify system flaws that can be corrected to prevent the error from happening again (Ogrinc & Huber, 2018). A root cause analysis can be used to see where an error happened and what can be done to improve the situation. In this situation multiple preventable errors occurred, in which a patient ended of dying. Mr. B died because of improper protocols, lack of staffing and poor patient follow-up. In circumstance we need to learn from the unfortunate mistakes. A1: RCA STEPS The primary step is to identify the problem, why did it happen and how can it be prevented in the future. Then an RCA team is formed. This team can include members through all aspects in which the error occurred. It can include management, nursing, laboratory, clerical and custodial. It depends on the situation, who might be included on the team. The first step of RCA is identifying what happened, how did it happen. The team is responsible for finding out what happened from those involved with the incident. This information can be obtained from team members or from incident reports. The second step is to determine exactly what should have happened. What were the correct steps that should have been taken in the ideal situation. After that we move onto the third step, determin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. . . . . . . . . . . . . . . . . . .. . . . .

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