RTT1 Task 2

Topics: Nursing, Patient, Registered nurse, Licensed practical nurse / Pages: 10 (3259 words) / Published: May 7th, 2015
RTT1 Task 2
Organizational Systems and Quality Leadership
Western Governors University
Leslie Baylor

A. Complete a root cause analysis (RCA) that takes into consideration causative factors that led to the sentinel event (this patient’s outcome).

“A central tenet of Root Cause Analysis (RCA) is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals” (AHRQ,
2012). The prevention of errors is the main emphasis of a RCA. The process begins with gathering data in regards to the event, then the data needs to be analyzed, and the final step is to find solutions to the errors that were found so that a reoccurrence of the same error doesn’t occur again. The team should consist of nurses, physicians, pharmacists, therapists, hospital administrators. Once the team is assembled they should work through the RCA process. This should begin with the patient and staff involved in the error being interviewed so data can be obtained that is important to the situation. The team then works together to find the root(s) of the problem. Once the root problem(s) is found the team comes up with solution(s) to help the error to not occur again.

There were multiple smaller events that led to the adverse event in the case of Mr. B. When the case is looked at there are several things that can be identified as part of the problem. Human and facility errors can be part of the result of the adverse event that occurred.

In this case Mr. B, a 67 year old male patient presented, to the rural hospital that has a 6 bed
Emergency Department (ED), with severe pain to his left hip secondary to a fall.


seeking care he came across some obstacles that led to his death. One of the main obstacles that he ran into was the staffing in the ED, which consisted of only one Registered Nurse (RN),
Nurse J., one Licensed Practical Nurse (LPN), one Physician (MD), Dr. T, and a secretary.
Upon Mr. B’s arrival the the ED there were

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