Root Cause Analysis

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Root Cause Analysis & Failure Mode and Effects Analysis Western Governors University Organizational Systems and Quality Leadership, RTT1 Task 2 The purpose of this paper is to examine the unfortunate sentinel even of Mr. B, who was a sixty-seven year-old patient brought to the emergency department by his son and neighbor after experiencing a fall. I will conduct a root cause analysis to help determine the causative factors that led to Mr. B’s sentinel event. In the process of completing a root cause analysis, I will discuss the errors and hazards of the care of Mr. B. Change theory will be utilized to develop an improvement plan to decrease the likelihood of a reoccurrence of this sentinel event. A failure mode and effects analysis will be used to project the likelihood that the process improvement plan suggested would not fail. I will also discuss the key role nurses would play in improving the quality of care in the situation of Mr. B. Root Cause Analysis According to Root Cause Analysis for Beginners, “root cause analysis (RCA) is a process designed for use in investigating and categorizing the root causes of events with safety, health, environmental…impacts” (Rooney, 2004). The first step in doing a RCA is defining the problem. In the scenario of Mr. B’s sentinel event the problem is the untimely death of Mr. B, which could have turned out differently. The second step of a RCA is gathering information or the facts. The facts of this event are: Mr. B came to the emergency department after a fall, during the course of his health care stay he received medication that sedated him, he was not monitored according to the “conscious sedation” policy, which in turn resulted to the death of Mr. B. In step three of conducting a root cause I identify possible causal factors. The sequence of events that led up to this sentinel event is Mr.

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