Organizational Systems-Wgu-Task 2 Essay examples

2663 Words May 17th, 2016 11 Pages
Organizational Systems and Quality Leadership
Task 2
Jill Riccobono
Western Governors University

Organizational Systems and Quality Leadership Task 2
A. Root Cause Analysis
A root cause analysis (RCA) looks at an event and considers what happened, why it happened what will be done to prevent it from happening again and how will we know that the changes made will improve the safety of the system. It takes into consideration causative factors, errors and hazards that led to a sentinel event. In this case it was a patient’s death. RCA should not look to place blame on people, but rather processes that need to be improved.
The first step in a RCA is to identify what happened. In the scenario, presented in this task, the patient was
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In addition it appears that Mr. B’s medical history, including current regular use of Oxycodone had not been reviewed prior to the procedure. There is no mention of verification of frequency or dosage of his current usage. Mr. B could have taken the Oxycodone prior to arriving at the ED in a dosage, that when combined with the medication given, could have contributed to the outcome.
There were contributing factors, or hazards in this scenario that contributed to the aforementioned errors. Most notable of these were staffing issues, weak communication between the LPN and the RN, and failure to use proper procedures. It is evident in this scenario that both the LPN and the RN, were busy directing their focus in several different directions and taking care of other patients, including new admits and discharges. Being the only two nurses on the unit, the constant monitoring of Mr. B that was required did not happen. Yet, there was additional backup staff that was available and they were not utilized. Now that we have determined, what happened and looked at some possible causes of why it happened, it is up to the team that is performing the RCA to come up with a plan including what will be done to prevent it from happening again and monitoring the effectiveness of the plan to ensure that the changes made will

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