Rca and Fmea

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Root Cause Analysis: Root cause analysis (RCA) is used in different fields to conduct a systematic search to find the causes of a specific sentinel event (Jacob, 2010). The main goal for conducting a RCA is to prevent similar adverse events from happening in the future (Jacob, 2010). In this paper, I will use the scenario provided in the task to create a complete RCA report as well as improvement plans that will prevent similar incidents from happening again. RCA is best done as soon as an adverse event has happened (Jacob, 2010). The first step in the RCA is to identify what had happened (Jacob, 2010). In the scenario, Mr. B was admitted to the Emergency Room (ER) after a fall. During the treatment, Mr. B was given…show more content…
To do so, I am going to use the fishbone diagram to categorize the causative factors (Potter & Perry, 2008). For patient characteristics, Mr. B was a 67 year old patient with routine use of oxycodone to treat chronic pain. Because of his routine use of oxycodone, he may need a different dose to get to a sedated level than other people who are not on any medication. Next is the task factors, the hospital had a policy which requires that anyone who are treated with moderate sedation or analgesia have to be put on continuous blood pressure, ECG, and pulse oximeter monitoring until the procedure is done and patient is in stable condition. Mr. B was not being monitored accordingly during the sedation process. Another task factors is that all staffs must first complete a training module on sedation before performing the task. Individual staff is a factor too, Nurse J had completed the training module on sedation, he had an ACLS certification as well as experience working as a critical care nurse. Team factors include communication between staffs; an example would be the LPN not informing Nurse J or Dr. T when the alarm went off the first time, it showed that Mr. B had low oxygen saturation. Work environment factors included the staffing in the ER, the equipments they had, and the level of experience of the staffs. According to the scenario, additional staffs were available for back up support and all the equipment needed
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