Organizational Systems and Quality Leadership
Task 2: RCA and FMEA
Carrie O’Barr
October 5, 2019
Western Governors University
This study source was downloaded by 100000827506713 from CourseHero.com on 02-15-2022 02:20:45 GMT -06:00
https://www.coursehero.com/file/48215161/C489-Task2-RCA-FEMAdocx/
, A. Root Cause Analysis (RCA)
When a problem doesn’t have an “easy fix”, one could consider a more sophisticated
approach to problem solving. A Root Cause Analysis (RCA) is a multi-step process
formed to find an underlying cause of a problem. Identifying the root cause of a
problem(s) allows the opportunity to correct and hopefully prevent the error from
continuing.
1. RCA Steps
When a problem (not negligence or willful harm) has occurred, it typically doesn’t
happen in single incidents. A team of four to six people professionals with
knowledge of the issues are gathered to complete six steps in search of the root
cause analysis. The RCA steps, according to IHI and are as follows: 1) Identify what
happened. 2) Determine what should have happened. 3) Determine causes – ask
why five times. 4) Develop causal statements – what are the contributory factors. 5)
Generate a list of recommended actions to prevent the recurrence of the event. 6)
Write a summary and share it.
2. Causative and Contributing Factors
In conducting RCA on the scenario: Mr. B, was identified as a 67-year-old, 175
pound, male who presented L leg/hip pain to a small (60 bed) hospital, in an even
smaller (6 bed) ER. Mr. B stated that he lost his balance and tripped over his dog.
Upon arrival Mr. B’s BP, R and Temp were all within normal limits, his respirations
were noted to be elevated (possibly related to severe pain). He rated his pain a
10/10. He had shortening of his L leg, edema, ecchymosis and limited ROM. His
prior history was chronic back pain, impaired glucose tolerance, prostate cancer,
high cholesterol/high triglycerides. His home meds were for high cholesterol and
chronic pain. On staff in the ER Dept were: 2 nurses (a LPN and a RN), one ER
doctor, one secretary and a hospital respiratory therapist. At the time of Mr. B’s
arrival, he was the 3rd patient in the ER. After Mr. B’s doctor eval, he was given 5mg
of diazepam IV push, which did not seem to have an effect after 5 minutes. The
doctor ordered Hydromorphone 2mg IVP and it was given 10 minutes later. The
doctor, still unsatisfied with the level of sedation for hip reduction, ordered another
2mg of Hydromorphone and 5mg of diazepam. Mr. B’s hip was successfully
reduced, and he seemed to be resting with his son in the room. The ER was notified
This study source was downloaded by 100000827506713 from CourseHero.com on 02-15-2022 02:20:45 GMT -06:00
https://www.coursehero.com/file/48215161/C489-Task2-RCA-FEMAdocx/
Task 2: RCA and FMEA
Carrie O’Barr
October 5, 2019
Western Governors University
This study source was downloaded by 100000827506713 from CourseHero.com on 02-15-2022 02:20:45 GMT -06:00
https://www.coursehero.com/file/48215161/C489-Task2-RCA-FEMAdocx/
, A. Root Cause Analysis (RCA)
When a problem doesn’t have an “easy fix”, one could consider a more sophisticated
approach to problem solving. A Root Cause Analysis (RCA) is a multi-step process
formed to find an underlying cause of a problem. Identifying the root cause of a
problem(s) allows the opportunity to correct and hopefully prevent the error from
continuing.
1. RCA Steps
When a problem (not negligence or willful harm) has occurred, it typically doesn’t
happen in single incidents. A team of four to six people professionals with
knowledge of the issues are gathered to complete six steps in search of the root
cause analysis. The RCA steps, according to IHI and are as follows: 1) Identify what
happened. 2) Determine what should have happened. 3) Determine causes – ask
why five times. 4) Develop causal statements – what are the contributory factors. 5)
Generate a list of recommended actions to prevent the recurrence of the event. 6)
Write a summary and share it.
2. Causative and Contributing Factors
In conducting RCA on the scenario: Mr. B, was identified as a 67-year-old, 175
pound, male who presented L leg/hip pain to a small (60 bed) hospital, in an even
smaller (6 bed) ER. Mr. B stated that he lost his balance and tripped over his dog.
Upon arrival Mr. B’s BP, R and Temp were all within normal limits, his respirations
were noted to be elevated (possibly related to severe pain). He rated his pain a
10/10. He had shortening of his L leg, edema, ecchymosis and limited ROM. His
prior history was chronic back pain, impaired glucose tolerance, prostate cancer,
high cholesterol/high triglycerides. His home meds were for high cholesterol and
chronic pain. On staff in the ER Dept were: 2 nurses (a LPN and a RN), one ER
doctor, one secretary and a hospital respiratory therapist. At the time of Mr. B’s
arrival, he was the 3rd patient in the ER. After Mr. B’s doctor eval, he was given 5mg
of diazepam IV push, which did not seem to have an effect after 5 minutes. The
doctor ordered Hydromorphone 2mg IVP and it was given 10 minutes later. The
doctor, still unsatisfied with the level of sedation for hip reduction, ordered another
2mg of Hydromorphone and 5mg of diazepam. Mr. B’s hip was successfully
reduced, and he seemed to be resting with his son in the room. The ER was notified
This study source was downloaded by 100000827506713 from CourseHero.com on 02-15-2022 02:20:45 GMT -06:00
https://www.coursehero.com/file/48215161/C489-Task2-RCA-FEMAdocx/
