organizational systems and quality leadership c489 – task 2 rca amp fmea
western governors university organizational systems and quality leadership c489 – task 2 rca amp fmea
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C489
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Running Head: SAT 1 – SAT TASK 2: RCA & FMEA 1
Organizational Systems and Quality Leadership C489 – Task 2
Name
Date
Western Governors University
,SAT 1 – SAT TASK 2: RCA & FMEA 2
A. Root Cause Analysis - Purpose for conducting an RCA
Root Cause Analysis (RCA) is a systematic retrospective approach of discovery
by a team of four to six care professionals across the healthcare institution, which looks
into the system flaws that led to an adverse event in care. The RCA process has six
steps that are followed in an attempt to identify ways in which the identified flaws might
be corrected by a process improvement plan to prevent a reoccurrence (Institute for
Healthcare Improvement [IHI], n.d. - b).
A1. RCA Steps - The 6 steps of the Institute for Healthcare Improvement (IHI) RCA
There are six steps to an RCA as defined by the IHI; One, identify what happened.
Two, determine what should have happened, Three, determine the factors that led to the
event. Four, determine what effect each factor caused that contributed to the cascading string
of events that ultimately resulted in the adverse event in the first place. Five, generate a
recommended action list to prevent the event from occurring again. Six, write a summary and
share it with all departments and care teams to assist knowledge and process to prevent the
adverse event from re-occurring in the healthcare system as a whole (IHI, n.d. - b).
A2. Causative and Contributing Factors – Factors leading to the sentinel event
Step One: The 67-year-old male patient with a simple left hip fracture was over
sedated, improperly monitored and stopped breathing. The over sedation led to a
depressed respiratory response and cessation of breathing which resulted in
ventricular fibrillation, leading to cardiac arrest and eventual brain death due to anoxic
brain injury. The patient's brain death and removal from artificial life-sustaining
ventilation led to his subsequent death (Western Governors University [WGU], n.d.).
Step Two: Instead of death the patient should have received conscious sedation and reduction of his
left hip while having continuous electrocardiography (ECG) monitoring, blood
, SAT 1 – SAT TASK 2: RCA & FMEA 3
pressure (BP) monitoring, and pulse oximeter monitoring administered by available
respiratory therapy staff until fully awake with stable vital signs (VSS), no nausea or vomiting
(N/V), and able to void per hospital policy, then sent home for full recovery (WGU, n.d.).
Step Three: The multifactorial errors leading to this event include; Concomitant ordering
and administration of benzodiazepine and opioids. The ordering and administering of a double
or second dose of concomitant benzodiazepine and opioids in a short time frame from the first
administration is a contributing error, essentially doubling down on the first error. Not adhering
to the hospital’s standard protocol for conscious sedation monitoring is another significant factor
that led to harm in this case. Not summoning the extra available nursing and respiratory staff
when a new emergency was inbound, caused the existing staff to become distracted with other
care duties and contributed to errors in this case. Not placing the at-risk patient on oxygen was
another factor in the string of events. Simply resetting the oximetry alarm was another error. Not
calling a rapid response immediately when the patient’s oximetry reading was 85% was yet
another significant error (WGU, n.d.).
Step Four: The effects each error caused were significant. None was more significant than
the first by not following hospital protocol for conscious sedation; however, each subsequent error
compounded the first error. Concomitant ordering and administration of benzodiazepine and opioids
are known respiratory depressive medications, double dose administrations of those concomitant
medications within minutes of the first concomitant medication administration acted dramatically to
quickly depress the 67-year-old patient’s respiratory system to such a degree that the patient
experienced complete respiratory failure and cardiac arrest via atrial fibrillation within 8 minutes from
the RN’s last assessment. The resulting respiratory failure likely resulted in cardiac arrest via atrial
fibrillation which stopped blood flow to the brain resulting in brain anoxia and ultimately led to the
brain death of the patient (WGU, n.d.).
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