Root Cause Analysis, Change Theory, FMEA, and Nursing Root Cause Analysis (RCA)

3232 WordsMar 1, 201413 Pages
RUNNING HEAD: RTT1 TASK 2 1 RTT1 Task 2: Root Cause Analysis, Change Theory, FMEA, and Nursing Western Governors University RTT1 TASK 2 2 RTT1 Task 2: Root Cause Analysis, Change Theory, FMEA, and Nursing Root Cause Analysis (RCA) A root cause analysis (RCA) is an essential tool that can be used to examine and understand the ways in which systems fail as well as discuss those specific failures that led to a specific adverse event and potentially implement steps or behaviors to prevent that event from happening in the future (Ogrinc & Huber, 2013). In the case study presented, a number of system failures may have contributed to the patient outcome. As such, an RCA of the case study would help determine those specific…show more content…
A flow chart in this step of the process should be utilized as well in order to aid in the visualization of the ideal behaviors. This process may also RTT1 TASK 2 4 help point out additional behaviors or improvements in the system otherwise overlooked in the verbal or written analysis phase. After careful analysis of what had happened and what should have happened takes place, the RCA team should ideally focus on why the adverse events happened. In this step, the goal is pinpoint the direct causes and contributory factors (Ogrinc & Huber, 2013). By doing this, the root cause of an event can be identified. One suggestion made by the Institute of Healthcare Improvement in the root cause analysis process is to ask “Why?” five times (Ogrinc & Huber, 2013). 1. Why did this happen? a. The LPN silenced the alarm notifying the staff about the Mr. B’s O2 saturation of 85%. 2. Why was it silenced? a. The LPN was engaged in caring for the emergency transport patient along with the RN and was also in the process of discharging the other two patients. 3. Why did the LPN not notify the RN of the alarm and reading? a. With the information provided, it appears that the LPN was distracted as well as did not follow her scope of practice. 4. Why was the LPN distracted? a. Additional or backup staff that was available per the information provided was not present or available to assist with discharges and the care of the acute respiratory distress patient. 5. Why was

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