C489 Task 2 RCA and FMEA Organizational Systems and Quality Leadership C489 Task 2 RCA

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C489 Task 2 RCA and FMEA Organizational Systems and Quality Leadership C489 Task 2 RCA and FMEA Western Governors University A- Root Cause Analysis (RCA) The given scenario involves Mr. B,... a 67-year-old man who fell at home and broke his hip and when taken to the hospital in order to get treatment ended up dying as a result of errors and safety violations from his care team. A RCA is a tool used to analyze an adverse event in order to find contributing factors and causes of errors that can be improved or prevented. According to the Institute for Healthcare Improvement (2018), there are six steps involved in the RCA process that are: forming a team, identifying what happened, determining what should have happened, determining causes and contributors, developing causal statements, and recommending actions. In order to conduct a RCA, it is important to form a multidisciplinary team consisted of four to six members who have knowledge of the processes and implications involved in the incident. In this scenario, the RCA team may be composed of an emergency room physician, critical care nurse, risk management, quality improvement, and experienced LPN. Other members of the hospital management team and the ethic and legal team may be involved as well because the incident resulted in death. Each team member will be assigned a role in order to better analyze the situation. The next step involved in the RCA process is identifying what happened. This step is the information-gathering phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. . . . . . . . . . . . . . . . . . .. . . . . [Show More]

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