C489 Task 2 .docx Organizational Systems and Quality Leadership SAT Task 2 Western Go

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C489 Task 2 .docx Organizational Systems and Quality Leadership SAT Task 2 Western Governors University Organizational Systems and Quality Leadership SAT Task 2 A. Root Cause Analysis Root C... ause Analysis (RCA) is a tool to help understand the causes of an adverse event by identifying flaws in the system that can be fixed or correct to prevent the recurrence of the error. It is helpful in that it utilizes the systems approach to a mistake as opposed to placing blame on a single individual to try and identify areas that can be improved to avoid the error from happening again. (Institute for Healthcare Improvement, n.d.) A1. RCA Steps There are six steps to all RCAs. The first is to identify the error most accurately and thoroughly as possible. This can be done by utilizing a flow-chart to have a visual representation of what lead to the event in the order in which it occurred. The second step is to determine what should have happened. This is when the team determines under ideal/normal circumstances, the actual actions that should have taken place. A flow chart can also be used in this step to help compare to what happened. The third step to determine the causes or “ask WHY five times.” Direct causes and contributory causes are discussed in this step. Another useful tool in this step is a “fishbone diagram – Ishikawa/cause and effect diagram,” which is a graphic tool to display the possible causes of a particular effect. Step four is to develop causal statements,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. . . . . . . . . . . . . . . . . . .. . . . . [Show More]

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