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SAT1 — SAT TASK 2: RCA AND FMEA ORGANIZATIONAL SYSTEMS AND QUALITY LEADERSHIP — C489 PRFA — SAT1 TASK OVERVIEWSUBMISSIONSSCORE REPORTS SELECT EVALUATION Attempt 1 Attempt 1 SCORE REPORT — ATTEMPT 1 — REVISION NEEDED Overall Evaluator Comments EVALUATOR COMMENTS A promising submission on RCA and FMEA is provided and a wonderful presentation of the causative and contributing factors is shown, including the patient not being monitored, inadequate staffing, and over sedation. A valid improvement plan is provided, such as increasing staff in the ED. A feasible discussion on the nurse demonstrating leadership and being involved in RCA and FMEA process, is provided. The change theory, general purpose of the FMEA process, and the testing intervention is not evident or fully developed in this submission. A. ROOT CAUSE ANALYSIS Competent A1. RCA STEPS Competent A2. CAUSATIVE AND CONTRIBUTING FACTORS Competent B. IMPROVEMENT PLAN Competent B1. CHANGE THEORY Approaching Competence Approaching CompetenceThe discussion does not logically describe how Lewin’s change theory could be applied to the proposed improvement plan, or the discussion does not describe each phase of the ...
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