C489_Task2.docx C-489 Organizational Systems and Quality Leadership SAT Task 2 Weste

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C489_Task2.docx C-489 Organizational Systems and Quality Leadership SAT Task 2 Western Governors University Organizational Systems and Quality Leadership SAT Task 2 A. Root Cause Analysis Roo... t Cause Analysis (RCA) is a tool and process used to determine preceding causes to an event. This is an approach to error by reviewing the systems, to correct system failure, and to prevent future harm (IHI, 2015). The RCA seeks to understand and respond to root causes. The systems approach is not looking to blame individuals but to study the systems and make changes of improvement to prevent further errors from happening. As in the name, RCA is analyzing for a root cause, why, how, and what will be done for improvement and prevention of further incidents. The goal is to understand the event or issue, find its cause, resolve the issue so it will not happen again and then improve the process. A1. RCA Steps When an event happens, the patient and family need to be cared for. The situation/area needs to be made safe for others, and all equipment, materials, or medications that were used need to be sequestered (IHI, 2105). When the event is determined that an RCA is to be done, a team is formed, and the following steps are performed: 1.The problem needs to be defined, what happened, who was involved, what was involved, when did it happen, and where did it happen? The investigation begins with these questions. Any equipment or medications used should be examined and placed in a sec. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. . . . . . . . . . . . . . . . . . .. . . . . [Show More]

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