Organizational Systems-Wgu-Task 2

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Organizational Systems and Quality Leadership Task 2 Jill Riccobono Western Governors University Organizational Systems and Quality Leadership Task 2 A. Root Cause Analysis A root cause analysis (RCA) looks at an event and considers what happened, why it happened what will be done to prevent it from happening again and how will we know that the changes made will improve the safety of the system. It takes into consideration causative factors, errors and hazards that led to a sentinel event. In this case it was a patient’s death. RCA should not look to place blame on people, but rather processes that need to be improved. The first step in a RCA is to identify what happened. In the scenario, presented in this task, the patient was…show more content…
Improvement Plan While there was a policy in place for conscious sedation, even good policies rely on the vigilance of staff to adhere to them. Often times, working conditions allow for distractions, and even the best of practitioners, with the best of intentions, make errors. There were several areas presented in this scenario that require examination and improvement. First of all, in order to improve patient safety, staffing levels need to be appropriate. In this case, as the patient load increased, the staffing level did not. There was only one RN and on LPN on duty. As a proponent of acuity based staffing, I would have a system in place that allowed for staff to be assigned based on a patient acuity scoring system that would be implemented, that would staff the unit not only based on the number of patients but also for the care required. In this case we have a patient that requires constant monitoring, as well as another emergent respiratory distress patient. Had another nurse been assigned to the unit, Nurse J, who was trained in conscious sedation, would have been able to adhere to the existing policy and provide constant monitoring of Mr. B which most likely would have avoided the outcome presented in this scenario. Again though, policies are only as good as long as they are followed and staff is aware of them. More than just having a policy exist, there needs to be double checks, check lists and ongoing education. In instances

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