Running head: Organizational Systems Task 2 1
Organizational Systems and Quality Leadership
Task 2; SAT1-0517
Western Governors University
, Running head: Organizational Systems Task 2 2
A. Root Cause Analysis
A root cause analysis is a multi-disciplinary team oriented systematic approach to learn from a
mistake and identify actionable causes that can be prevented to decrease the likelihood of the
same mistake happening again (Retrieved from http://app.ihi.org/lmsspa/#/6cb1c614-884b-43ef-
9abd-d90849f183d4/614af4d5-09ed-4c08-b495-59673b0a581a/lessonDetail/82f42955-31f0-
40b2-bad2-c297a1e98f6c/page/0). There are 4 questions an RCA seeks to answer in order to
trigger improvement in an organization: 1. What happened, 2. Why did it happen, 3. What can be
done to prevent it from happening again, and 4. How will it be known that changes made have an
impact on safety (Retrieved from http://app.ihi.org/lmsspa/#/6cb1c614-884b-43ef-9abd-
d90849f183d4/614af4d5-09ed-4c08-b495-59673b0a581a/lessonDetail/82f42955-31f0-40b2-
bad2-c297a1e98f6c/page/0).
A1. RCA Steps
The first step of Root Cause Analysis, or RCA, is to form a team (Retrieved from
http://app.ihi.org/lmsspa/#/6cb1c614-884b-43ef-9abd-d90849f183d4/614af4d5-09ed-4c08-b495-
59673b0a581a/lessonDetail/82f42955-31f0-40b2-bad2-c297a1e98f6c/page/0). The RCA team
should be able to represent fundamental knowledge of the issues and processes involved which
will require the participation of many different department within the hospital. The team should
also include employees at different levels in the departments – from bedside nurses to nursing
leaders, from environmental service workers to hospital administrators (Retrieved from
http://app.ihi.org/lmsspa/#/6cb1c614-884b-43ef-9abd-d90849f183d4/614af4d5-09ed-4c08-b495-
59673b0a581a/lessonDetail/82f42955-31f0-40b2-bad2-c297a1e98f6c/page/0).
Step 2 is the information gathering phase designed to determine what happened. The team should
seek to give a correct and comprehensive description of the event in order to pinpoint the most
Organizational Systems and Quality Leadership
Task 2; SAT1-0517
Western Governors University
, Running head: Organizational Systems Task 2 2
A. Root Cause Analysis
A root cause analysis is a multi-disciplinary team oriented systematic approach to learn from a
mistake and identify actionable causes that can be prevented to decrease the likelihood of the
same mistake happening again (Retrieved from http://app.ihi.org/lmsspa/#/6cb1c614-884b-43ef-
9abd-d90849f183d4/614af4d5-09ed-4c08-b495-59673b0a581a/lessonDetail/82f42955-31f0-
40b2-bad2-c297a1e98f6c/page/0). There are 4 questions an RCA seeks to answer in order to
trigger improvement in an organization: 1. What happened, 2. Why did it happen, 3. What can be
done to prevent it from happening again, and 4. How will it be known that changes made have an
impact on safety (Retrieved from http://app.ihi.org/lmsspa/#/6cb1c614-884b-43ef-9abd-
d90849f183d4/614af4d5-09ed-4c08-b495-59673b0a581a/lessonDetail/82f42955-31f0-40b2-
bad2-c297a1e98f6c/page/0).
A1. RCA Steps
The first step of Root Cause Analysis, or RCA, is to form a team (Retrieved from
http://app.ihi.org/lmsspa/#/6cb1c614-884b-43ef-9abd-d90849f183d4/614af4d5-09ed-4c08-b495-
59673b0a581a/lessonDetail/82f42955-31f0-40b2-bad2-c297a1e98f6c/page/0). The RCA team
should be able to represent fundamental knowledge of the issues and processes involved which
will require the participation of many different department within the hospital. The team should
also include employees at different levels in the departments – from bedside nurses to nursing
leaders, from environmental service workers to hospital administrators (Retrieved from
http://app.ihi.org/lmsspa/#/6cb1c614-884b-43ef-9abd-d90849f183d4/614af4d5-09ed-4c08-b495-
59673b0a581a/lessonDetail/82f42955-31f0-40b2-bad2-c297a1e98f6c/page/0).
Step 2 is the information gathering phase designed to determine what happened. The team should
seek to give a correct and comprehensive description of the event in order to pinpoint the most
