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Running head: ORGANIZATIONAL SYSTEMS TASK 2

Organizational Systems and Quality Leadership

Task 2 RCA and FMEA; SAT1-1217

Nuttiraporn Hanson

Western Governor University

ORGANIZATIONAL SYSTEMS TASK 2

A. Root Cause Analysis

Root Cause Analysis (RCA) is a method to help identify how and why an event occurred

underlying variation in performance, and it is the best tool for problem solving. The RCA

focuses on systems and processes. The RCA will help prevent a serious safety event, a near-miss

event, or a less serious event in the future. The RCA is a powerful tool for health care

organizations. It can help reduce and prevent errors and improve quality of care.

A1. RCA Steps

Step 1: Identify what happened

In this scenario, Mr. B, a 67-year-old gentleman, fell at home after tripping over his dog.

He moaned and complained of severe left hip and leg pain. Nurse J and Dr. T performed

moderate sedation/analgesia to treat Mr. B. They administered 10 milligrams of diazepam and 4

milligrams of hydromorphone through an IV access. Within 10 minutes, Mr. B was sedated.

They continually monitored Mr. B’s blood pressure and oxygen saturation, but they did not

monitor Mr. B’s EKG. A licensed practical nurse (LPN) was aware that Mr. B’s saturation was

low at 85% on room air. However, she did not provide any oxygen supplement for Mr. B, but she

reset the alarm instead. Mr. B was in ventricular fibrillation (V-Fib) and stopped breathing. Mr.

B’s blood pressure was 58/30, and oxygen saturation was 79%. The code team resuscitated Mr.

B, and they were able to convert his EKG from V-Fib to a normal sinus rhythm with a pulse and

a blood pressure of 110/70. However, Mr. B could not breathe on his own, and he depended on

the ventilator. Mr. B was transferred to another facility for a higher level of care. The lack of

adequate nurse staffing caused adverse events of Mr. B. Staffing on the day of the sentinel event

was one registered nurse (RN), one LPN, one secretary, and one ER physician. The scenario

suggested that before Mr. B’s arrival. The staffs cared for two patients. Later on, both Nurse J

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Running head: ORGANIZATIONAL SYSTEMS TASK 2 Organizational Systems and Quality Leadership Task 2 RCA and FMEA; SAT1-1217 Nuttiraporn Hanson Western Governor University 1 ORGANIZATIONAL SYSTEMS TASK 2 2 A. Root Cause Analysis Root Cause Analysis (RCA) is a method to help identify how and why an event occurred underlying variation in performance, and it is the best tool for problem solving. The RCA focuses on systems and processes. The RCA will help prevent a serious safety event, a near-miss event, or a less serious event in the future. The RCA is a powerful tool for health care organizations. It can help reduce and prevent errors and improve quality of care. A1. RCA Steps Step 1: Identify what happened In this scenario, Mr. B, a 67-year-old gentleman, fell at home after tripping over his dog. He moaned and complained of severe left hip and leg pain. Nurse J and Dr. T performed moderate sedation/analgesia to treat Mr. B. They administered 10 milligrams of diazepam and 4 milligrams of hydromorphone through an IV access. Within 10 minutes, Mr. B was sedated. They continually monitored Mr. B’s blood pressure and oxygen saturation, but they did not monitor Mr. B’s EKG. A licensed practical nurse (LPN) was aware that Mr. B’s saturation was low at 85% on room air. However, she did not provide any oxygen supplement for Mr. B, but she reset the alarm instead. Mr. B was in ventricular fibrillation (V-Fib) and stopped breathing. Mr. B’s blood pressure was 58/30, and oxygen ...
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