Organizational Systems and Quality Leadership Task 2 Western Governors University 03/15/2015 Root cause analysis (RCA) is one of the organized techniques that can be used as an analyzer in any events of adverse events. In health care settings the best method to track down an adverse event and find out the root cause of the problem‚ would increase the overall patient well-being outcome. The best approach to an adverse event would be to set up questions systematically from the point
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ROOT CAUSE: In this case‚ we believe that there are three main root causes from the management of this company‚ especially in packaging department. The first main one is cohesiveness limited the productivity in packaging department. Cohesiveness for packing department was existent and had become somewhat negative. Employees were mimicking the bad behavior of one another and were failing to get anywhere production wise. Packing department seemed to be small knit group and they were able to complete
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ACA or the Obamacare has two main focuses‚ which also known as root causes. They were to increase insurance coverage and cut down cost. With mandatory insurance coverage and introduction of out of pocket limits (the maximum amount of costs for covered services paid out-of-pocket) for individuals and households‚ the government is trying to prevent the excess health care expense burden that people face due to varying health insurance policy (Bose‚ 2016). The major coverage provisions of the ACA went
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Root Cause Analysis (RCA) is a process that is used to identify the causes of an error or accident. In the case of Mr. B death‚ a RCA is needed to determine what may have contributed to his death. A Root Cause analysis must be complete and reported to Joint Commission in the even where injury or death occurs. Sentinel event is a major adverse even that could have been prevented (Alemi‚ 2007). The sentinel event was related to respiratory arrest secondary to conscious sedation procedure. The people
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Root Cause Analysis (RCA) is a tool to find the root factor in a failure of a system or of a process. In a RCA‚ we always want to establish the chain of events first. Reviewing the second scenario we have a Mr. B‚ the patient‚ Dr. T‚ RN J and an LPN with no initial. Mr. B comes into the ER with a hip dislocation at 15:30. He is triaged‚ assessed‚ history obtained‚ placed in ER room and the ER physician is updated on patient status and history. Mr. B’s vitals at this time are B/P 120/80‚ HR 88
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subsequent comparison. Analyze : Determination of the causal relationships within the process. Determine what kind of relationship is involved and make sure that all factors have been considered. Improve : Improve or optimize the process based on the analysis‚ using techniques such as Design of Experiments. Control : Continuously monitor the process as it continues using the measuring systems developed. Set up appropriate corrective actions for anticipated deviations in the process. * Relate with
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Regulatory Integrity Manager‚ I am responsible for managing a team of 5 bespoke complaints specialists. The teams role is to make sure regulatory reporting to the appropriate bodies are correct and delivered within SLAs. In addition‚ conduct root cause analysis and produce policy and procedure documents within a controlled framework to make sure delivery
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RUNNING HEAD: RTT1 TASK 2 1 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
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ROOT CAUSE ANALYSIS OF A SENTINEL EVENT Diane Swintek Western Governors University Root Cause Analysis of a Sentinel Event A root cause analysis (RCA) is a method by which we can examine a serious adverse event and identify the cause‚ or causes‚ that led up to the event. Although personnel are involved in these events‚ the primary purpose of the RCA is to identify the cause‚ not to assign blame (Agency for Healthcare Research and Quality‚ 2014). It is through identifying a cause‚ or
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events such as root cause analysis‚ change theory and failure mode and effects analysis using the scenario involving Mr. B in Task 2 instructions. A. Root Cause Analysis Nursing is a profession of helping others. Those who choose to work in healthcare never intended on harming. However‚ if harm does come to a patient proper policy and procedure should be followed after
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