Organizational Systems and Quality Leadership Task 2
A. Root Cause Analysis
What is a root cause analysis (RCA)? It is a way to understand errors; why they happen, what caused them and how can we stop this error from happening again. Hospitals can use RCA to understands sentinel events. When applied successfully, RCA is an effective system- and team-oriented approach to learning from failures and triggering improvement, Ogrinc, G and Huber, S (2010). The next steps after the event are to set up a team to investigate, investigate the incident and identify the causes.
Gathering information is the first step; asking why and then asking why again until all the pieces fit together to tell the story. In the scenario for this task, a patient died because there where causative factors and errors that took place. A cause and effect or fishbone diagram would be useful in …show more content…
FMEA Failure modes and Effects Analysis (FMEA) according to Sauls, K (2013) is a tool used to anticipate and prevent problems. The idea behind the use of this tool is that areas where change is needed can be identified by proactive evaluation of processes where failure is most likely to occur. The FMEA looks at failure, what causes it and what the consequences are.
C1. Members of the Interdisciplinary Team A multidisciplinary team is needed to promote the best outcome involving all perspectives. The team would be made up of a representative from each category of nursing and support staff, a physician representative. The preference would be to involve the chief of department with this to support presenting the outcome to other physicians. I also think it would be prudent to have an administrator selected along with at least one nurse from the operating room or a surgery center who is familiar with conscious sedation. Also, a respiratory therapist perspective could be beneficial in this setting. Administrative staff are a must as their skills for organization and formatting documentation are an
A. Root Cause Analysis
What is a root cause analysis (RCA)? It is a way to understand errors; why they happen, what caused them and how can we stop this error from happening again. Hospitals can use RCA to understands sentinel events. When applied successfully, RCA is an effective system- and team-oriented approach to learning from failures and triggering improvement, Ogrinc, G and Huber, S (2010). The next steps after the event are to set up a team to investigate, investigate the incident and identify the causes.
Gathering information is the first step; asking why and then asking why again until all the pieces fit together to tell the story. In the scenario for this task, a patient died because there where causative factors and errors that took place. A cause and effect or fishbone diagram would be useful in …show more content…
FMEA Failure modes and Effects Analysis (FMEA) according to Sauls, K (2013) is a tool used to anticipate and prevent problems. The idea behind the use of this tool is that areas where change is needed can be identified by proactive evaluation of processes where failure is most likely to occur. The FMEA looks at failure, what causes it and what the consequences are.
C1. Members of the Interdisciplinary Team A multidisciplinary team is needed to promote the best outcome involving all perspectives. The team would be made up of a representative from each category of nursing and support staff, a physician representative. The preference would be to involve the chief of department with this to support presenting the outcome to other physicians. I also think it would be prudent to have an administrator selected along with at least one nurse from the operating room or a surgery center who is familiar with conscious sedation. Also, a respiratory therapist perspective could be beneficial in this setting. Administrative staff are a must as their skills for organization and formatting documentation are an