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Summary C489 Task 2.docx (1) C489 C489 €“ RCA AND FMEA €“ Task 2 College of Health Professions, Western Governors University C489: Organizational Systems and Quality Leadership C489- RCA AND FMEA €“ Task 2 The Root Cause Analysis method is used to identiR135,47
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Summary C489 Task 2.docx (1) C489 C489 €“ RCA AND FMEA €“ Task 2 College of Health Professions, Western Governors University C489: Organizational Systems and Quality Leadership C489- RCA AND FMEA €“ Task 2 The Root Cause Analysis method is used to identi
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C489 Task (1) C489 C489 €“ RCA AND FMEA €“ Task 2 College of Health Professions, Western Governors University C489: Organizational Systems and Quality Leadership C489- RCA AND FMEA €“ Task 2 The Root Cause Analysis method is used to identify or get to the root cause of a probl...
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C489
C489 – RCA AND FMEA – Task 2
College of Health Professions, Western Governors University
C489: Organizational Systems and Quality Leadership
C489- RCA AND FMEA – Task 2
The Root Cause Analysis method is used to identify or get to the root cause of a problem by
correcting or eliminating it and preventing its recurrence (McFarland, 2013).
According to the institute for Healthcare Improvement (IHI), there are six steps used to conduct
an RCA.
The first step is to define the problem. The team states what happened. A flowchart is created.
The second step is to collect data. The team determines what should have happened in optimal
circumstances and develop a flowchart on the given information and compare it with the
flowchart in step 1.
The third step is to establish the cause. The team analyzes the most relevant details. Ask “why”
repeatedly to find out the issue that caused the problem.
The fourth step is to find solutions. Determine which factors are root causes. What caused the
effect and what was the main event that resulted to initiate the RCA.
The fifth step is to identify corrective actions.
The sixth and final step is to develop a list of suggested actions to prevent recurrence of the
event, then implement the solution. Document the results.
, Causative and Contributing Factors
Applying the RCA process in the case of Mr. B, there were many factors that contributed to this
outcome. Considering these factors, it can be concluded that the primary cause of Mr. B’s
eventual death was the overdose of the sedatives diazepam and hydromorphone. The first error to
occur is not following proper procedure for conscious sedation. The nurse placed the pulse
oximetry, but she did not place the patient on continuous blood pressure monitoring, it was set to
read every five minutes. He also was not on continuous ECG, during the procedure, despite all of
these factors are required per policy. The patient was given too much sedation over a short period
of time without through assessment. No supplemental oxygen was applied during or after
procedure despite the risk of hypoxia with sedation. The first alarm of O2 saturation at 85%
discovered by the LVN was never reported to the RN or doctor so that appropriate interventions
could have been implemented. This patient required continuous monitoring, and that factor was
neglected due to the short staff available.
Improvement Plan
The three stages of change according to Lewin’s change theory are first to unfreeze, change
process, and refreeze (Burnes, 2004). This process is achieved by employee involvement in
change, knowledge sharing, leadership, and implementation of change. An organizational change
is then reached. The first step in developing an improvement plan is to unfreeze, which involves
preparing the organization to accept that a change is necessary. First, we will form a team. In
reference to this case, members of the team may include the emergency room doctor, primary
nurse, LPN, nurse manager, manager from respiratory therapy, and a representative from risk
management. Together they will determine what took place, conducting a flow chart outlining
the events in order of occurrence. The team could find this information through interviews and
medical records. Some of the issues observed in this scenario are, the emergency room is short
staffed, the nurse was not present pre-procedure to post procedure, and the appropriate vital signs
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