Organizational Systems Task 2 1
Organizational Systems and Quality Leadership
SAT Task 2
Jenny Juliana Mick
Western Governors University
05/31/2020
, Organizational Systems Task 2 2
Organizational Systems and Quality Leadership SAT Task 2
A. Root Cause Analysis
Root cause analysis or RCA is defined as a “systematic approach to understanding
the causes of an adverse event and identifying system flaws that can be corrected to prevent the
error from happening again (IHI).” A root cause analysis evaluates the past actions of an event to
learn and grow from the adverse error/harm caused to a patient. Typically, in a RCA, you want to
focus on the system causes then to place blame on individuals.
A1. RCA Steps
A root cause analysis is comprised of a total of six steps that needs to be followed.
The first step is to identify how the event occurred and portray the event in its entirety so that the
RCA team can identify what happened. In this step the team will organize and clarify the event in
question and can create a flowchart to depict the order of events. Step two of an RCA, the team
will put together the events in conditions that are ideal to determine what should have happened.
The team will put together an “ideal” flowchart to compare it to the data/flowchart from step 1.
In step three, the team will ask the why to the causes of the events. This is where the team
establishes the factors that contributed to the event in question. Potentially, the team should ask
the why five times to get to underlying or root cause of the event. Step four, the team explains
the contributory factors in a causal statement that links the cause and effect back to the main
event. Step five, the team creates a list of recommended actions or changes that can prevent the
recurrence of the sentinel event in future practice. In this step recommendations often fall in
categories or actions to generate these changes. Step six, the team can summarize the steps of
improvement and implement these changes. The team can then disseminate the information to
the hospital for future changes.
05/31/2020
Organizational Systems and Quality Leadership
SAT Task 2
Jenny Juliana Mick
Western Governors University
05/31/2020
, Organizational Systems Task 2 2
Organizational Systems and Quality Leadership SAT Task 2
A. Root Cause Analysis
Root cause analysis or RCA is defined as a “systematic approach to understanding
the causes of an adverse event and identifying system flaws that can be corrected to prevent the
error from happening again (IHI).” A root cause analysis evaluates the past actions of an event to
learn and grow from the adverse error/harm caused to a patient. Typically, in a RCA, you want to
focus on the system causes then to place blame on individuals.
A1. RCA Steps
A root cause analysis is comprised of a total of six steps that needs to be followed.
The first step is to identify how the event occurred and portray the event in its entirety so that the
RCA team can identify what happened. In this step the team will organize and clarify the event in
question and can create a flowchart to depict the order of events. Step two of an RCA, the team
will put together the events in conditions that are ideal to determine what should have happened.
The team will put together an “ideal” flowchart to compare it to the data/flowchart from step 1.
In step three, the team will ask the why to the causes of the events. This is where the team
establishes the factors that contributed to the event in question. Potentially, the team should ask
the why five times to get to underlying or root cause of the event. Step four, the team explains
the contributory factors in a causal statement that links the cause and effect back to the main
event. Step five, the team creates a list of recommended actions or changes that can prevent the
recurrence of the sentinel event in future practice. In this step recommendations often fall in
categories or actions to generate these changes. Step six, the team can summarize the steps of
improvement and implement these changes. The team can then disseminate the information to
the hospital for future changes.
05/31/2020
