Root Cause Analysis, Change Theory, FMEA, and Nursing Root Cause Analysis (RCA)
RUNNING HEAD: RTT1 TASK 2
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RTT1 Task 2: Root Cause Analysis, Change Theory, FMEA, and Nursing Western Governors University
RTT1 TASK 2
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RTT1 Task 2: Root Cause Analysis, Change Theory, FMEA, and Nursing Root Cause Analysis (RCA)
A root cause analysis (RCA) is an essential tool that can be used to examine and understand the ways in which systems fail as well as discuss those specific failures that led to a specific adverse event and potentially implement steps or behaviors to prevent that event from happening in the future (Ogrinc & Huber, 2013). In the case study presented, a number of system failures may have contributed to the patient outcome. As such, an RCA of the case study would help determine those specific failures and possibly ensure that this event would not happen in the future. Additionally, it is imperative to the process that four questions are answered: What happened? Why did it happen? What are we going to do to prevent it from happening again? How will we know that the changes we make will actually improve the safety of the system? (Ogrinc & Huber, 2013).
The first step in a RCA is to form a team that will be beneficial to the analysis process. Ideally, this team should include 4-6 people as well as be interdisciplinary in nature so as to provide unique perspectives on the system operations and interventions at hand (Ogrinc & Huber, 2013). Additionally, the team members should be from all different levels of the organization so as to foster appropriate changes if necessary in the system. Based on the case study presented, it would be important to have a nurse present from the unit/department where Nurse J and the LPN work, a respiratory therapist, a doctor that works for this hospital in the same capacity as Dr. T, a risk manager and a member of the quality improvement team. After the team is formed, the first step in the process is to identify what happened. In this particular case study, Mr. B was over sedated, not correctly
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RTT1 Task 2: Root Cause Analysis, Change Theory, FMEA, and Nursing Western Governors University
RTT1 TASK 2
2
RTT1 Task 2: Root Cause Analysis, Change Theory, FMEA, and Nursing Root Cause Analysis (RCA)
A root cause analysis (RCA) is an essential tool that can be used to examine and understand the ways in which systems fail as well as discuss those specific failures that led to a specific adverse event and potentially implement steps or behaviors to prevent that event from happening in the future (Ogrinc & Huber, 2013). In the case study presented, a number of system failures may have contributed to the patient outcome. As such, an RCA of the case study would help determine those specific failures and possibly ensure that this event would not happen in the future. Additionally, it is imperative to the process that four questions are answered: What happened? Why did it happen? What are we going to do to prevent it from happening again? How will we know that the changes we make will actually improve the safety of the system? (Ogrinc & Huber, 2013).
The first step in a RCA is to form a team that will be beneficial to the analysis process. Ideally, this team should include 4-6 people as well as be interdisciplinary in nature so as to provide unique perspectives on the system operations and interventions at hand (Ogrinc & Huber, 2013). Additionally, the team members should be from all different levels of the organization so as to foster appropriate changes if necessary in the system. Based on the case study presented, it would be important to have a nurse present from the unit/department where Nurse J and the LPN work, a respiratory therapist, a doctor that works for this hospital in the same capacity as Dr. T, a risk manager and a member of the quality improvement team. After the team is formed, the first step in the process is to identify what happened. In this particular case study, Mr. B was over sedated, not correctly
References: Bisognano M. (2010) Nursing 's role in transforming healthcare. Healthcare Executive. Institute for Healthcare Improvement. (2004). Failure mode and effects analysis (FMEA). Ogrinc, G., & Huber, S. Institute for Healthcare Improvement, (2013). How a root cause analysis works in clinical medicine. British Medical Journal, 316(7138), 1154-1157. doi: PMC1112945 Williams, D