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NSG C489 Task 2.
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NSG C489 Task 2. C 489 Task 2 Jessica Young Western Governors University 6/7/2020 A. Root Cause Analysis, according to the Institute for Healthcare Improvement (IHI), is a system wide method for understanding triggers for adverse events and finding...

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  • May 17, 2022
  • 8
  • 2022/2023
  • Exam (elaborations)
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  • nsg c489 task 2
  • nsg c489 task 2 c 489 task 2 jessica young western governors university 672020 a root cause analysis
  • according to the institute for healthcare improvement

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  • NSG C489

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RCA and FMEA
NSG C489 Task 2.
C 489 Task 2
Jessica Young
Western Governors
University 6/7/2020 RCA and FMEA
A.
Root Cause Analysis, according to the Institute for Healthcare Improvement (IHI), is a system wide method for understanding triggers for adverse events and finding errors in the system that need to be changed in order to prevent the same mistakes from happening in the future. RCA is a six-step process that usually involves 4-6 team members from different levels of
the entire organization who are familiar with the issue. (IHI 2020)
A1.
Step 1 identify what happened. Creating a flow sheet can help with a detailed picture of
the scenario.
Step 2 the team needs to determine what should have happened, it would be helpful to
make a second flow sheet and compare it to the one from step one.
Step 3 ask “why” questions to find contributing factors related to the event.
Step 4 develop a statement of trigger factors containing the cause, the effect, and the details of the event.
Step 5 make a list of recommended practice changes to prevent future occurrences such
as educating staff, and new or changes in policies.
Step 6 share the summary after you write it utilizing a flow sheet. (IHI, 2020)
A2.
The RCA staff are the ED doctor, the RN, the LPN the RT as well as a representative from risk management. Step one would be to identify the events. It is noted that Mr. B’s blood pressure and oxygen are on continuous monitoring, however respirations and ECG were not

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