A Root Cause Analysis ( Rca )

2131 WordsOct 8, 20149 Pages
A. Root Cause Analysis A root cause analysis (RCA) must be conducted when a sentinel event occurs in order to identify where the systems and pro cesses involved failed and how these systems may be improved to eliminate or reduce the risk for a reoccurring event of this type (Cherry , 2011 ) . The first step in conducting a root cause analysis is to form a committee of individuals that are from different levels of t he organization to review the failures of the system and processes that are associated to the event. This allows the committee to implement appropriate changes if necessary to the system and process to reduce the risk of a future ev ent of this nature havi ng . Based on the scenario provided Mr. B arrived at the hospital with a dislocated left hip, he was medicated to allow the ED physician to perform a left hip reduction and un expectantly codes in the emergency department and unfortunately passed away after b eing airlifted to a tertiary facility. Contributing factors in this event are identified as follows; a lack of knowledge regarding medication dosages and proper administration time , as well as conscious sedation procedure and hospital policy regarding consciou s sedation . A failure of commun icat ion played an important role as well. Furthermore, staffing of the emergency department the day of the event is questionable with one registered nurse and one licensed practical nurse (with limited qualifications ) to care for a six bed emergency room; o ther
Open Document