C489 SAT task 2: RCA and FEMA
WGU
C489 SAT task 2
A. Explain the general purpose of conducting a root cause analysis (RCA).
1. Explain each of the six steps used to conduct an RCA, as defined by IHI.
2. Apply the RCA process to the scenario to describe the causative and contributing
fact...
A. Explain the general purpose of conducting a root cause analysis (RCA).
1. Explain each of the six steps used to conduct an RCA, as defined by IHI.
2. Apply the RCA process to the scenario to describe the causative and
contributing
factors that led to the sentinel event outcome
A Root Cause Analysis RCA) is done to identify what went wrong and how to prevent the error
from happening again, this isn’t a problem that was caused by negligence or willful harm.
There are 6 steps, according to the IHI, to completing a RCA:
1) Identify what happened: This seems easy enough, but the event really needs to be
analyzed. Teams of 4 to 6 people need to be formed, sometimes including patients and
family members, but always consisting of all the people involved as well as individuals in
all levels of the organization. The team also needs support from all levels. ("IHI RCA
summary sheet," n.d.).
Scenario: Mr. B. came to a rural ED (a 6 room ED) with leg pain after tripping over
his dog. He presents with pain (10/10) in his left leg with shortening of the leg, edema in his
left calf, ecchymosis and limited ROM. His vital signs are within normal limits except for his
respirations which are elevated (could be due to pain). He is admitted to the ED with a past
medical history that includes chronic back pain, elevated cholesterol and impaired glucose
tolerance. He is currently taking atorvastatin (for his cholesterol) and oxycodone for chronic
back pain. He weighs 175lb. On staff in the ED were: 1 RN, 1 LPN, 1 secretary and 1 ED
MD (Dr. T) and a respiratory therapist who was in house and available.
At the time of Mr. B’s arrival there were 2 other patients in the ED who had been
evaluated, were stable and were awaiting lab results. Dr. T orders 5 mg of diazepam at 4:05,
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