RTT1

RTT Task 2 The provided scenario gives an account of a busy emergency department with competent staff, and the multiple errors that led up to the most severe error possible in healthcare, unnecessary death of a patient. A root cause analysis (RCA) can be utilized to help understand the systems at fault within the facility so that improvements can be determined and implemented to prevent any future occurrences (Cherry, 456). RCAs focus on systems rather than blaming individuals involved, therefore they are only appropriate in cases where there has been no willful negligence or criminal acts (Huber & Ogrinc, 2014). The overall purpose of RCAs is to find out the causes of the adverse event and determine how to keep similar errors from repeating in the future. Before the process can start, a team must be assembled as quickly as possible. The Institute for Healthcare Improvement suggests a multidisciplinary group of 4 to 6 individuals, including representation from a quality improvement department whenever possible (Huber & Ogrinc, 2014). The teams can then organize into roles such as; team leader, recorder, advisor and team members. The team can then start the process of the root cause analysis, which is to identify what happened. Conversation among the team, review of documentation such as incident reports will assist in giving a general outline and understanding of the event that occurred (Huber & Ogrinc, 2014). The team can next further clarify the details, potentially conducting further interviews or a cite visit can be of assistance for this. It is important for the team to get as much detail as possible regarding the event for the RCA to be effective. A flow chart showing the process of the event can then be made to assist with the next steps of the stage. Next, the team should determine what should have happened. This may involve policy and procedure review, research of best practice models and conversations with department heads and specialists