Rtt1 Task 2 Wgu

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Organizational Systems and Quality Leadership Task 2 Breanna Jordan Western Governors University Organizational Systems and Quality Leadership Task 2 A. Root Cause Analysis Although medical professionals take an oath to ‘do no harm’, errors in healthcare still occur. Patient safety is always priority when planning care for a patient; however adverse outcomes may take place resulting in a sentinel event. “A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response.” (CAMH, January 2013) To prevent these outcomes from repeating, a Root Cause Analysis (RCA) is initiated. A RCA is used to identify what caused an event to happen, why an event happened, and how to prevent the error from taking place in the future. To identify the origin of the event, a team is assembled consisting of; charge nurse, a physician, a respiratory therapist, a pharmacist, hospital administrators, and patients not directly involved in the case. First the team begins the investigation by interviewing patients and staff involved in incident, and accumulating all of the patient’s records to be reviewed. Once all necessary information is compiled, the team works together put together a sequence of events to determine what led to the adverse outcome. The team then analyzes which event(s) ultimately led to the outcome. Once these errors are identified the team collaborates to develop and implement interventions that may prevent the event from re-occurring. In this scenario there were several
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