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

3214 words 13 pages


RTT1 Task 2: Root Cause Analysis, Change Theory, FMEA, and Nursing Western Governors University



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
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Once the five “whys” have been addressed a clearer picture of the root cause of the event will manifest. In this case, it appears that a main causative factor could have been the lack of appropriate staff both for the monitoring of Mr. B and for the busy emergency department. As such, a revision of an existing policy or creation of a new policy that sets standards for staff matrices based on census be implemented. Another useful tool to use would be a fishbone diagram. In this case, Mr. B’s death could be used as the spine with contributory factors emerging along the spine to illustrate the factors contributing to the sentinel event. For example, lack of appropriate monitoring by ECG, silencing of the alarm by LPN, not notifying the RN of the alarm reading, distracted staff, lack of policy for calling in additional back up staff, over sedation, lack of appropriate chart review by MD, etc. can be used as contributing factors. According to Charles Vincent in an article titled, Framework for analyzing risk and safety in clinical medicine, there are seven factors that affect clinical practice and can be used as tools in the fishbone diagram or other objective analysis in this stage. They are patient characteristics, task factors, individual staff members, team factors, work environment, organizational and management factors


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