RTT1 Organizational Systems and Quality Leadership Task 2 - 75183

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RTT1 Task 2

Never events are serious medical errors that are often preventable. When such events transpire, it is necessary to fully assess the situation so that these errors can be prevented in the future. Root cause analysis (RCA) is a tool employed by healthcare facilities to analyze adverse events and the systems that lead to them.

A. Root Cause Analysis

“A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals” (AHRQ, 2012). The emphasis of RCA is on error prevention. It is a structured process of gathering data regarding the event, analyzing the information, and finding solutions to the problems to prevent reoccurrences. A team consisting of the charge nurse, a physician, a respiratory therapist, a pharmacist, hospital administrators, and patients not involved in the case is assembled to work through the process. The team begins by interviewing patients and staff involved to gather as much vital information as possible. Once all necessary information is compiled, the team works together to get to the root(s) of the problem.

In the case of Mr. B, there were multiple issues that led to the adverse event as opposed to one root problem. In the process of defining the problem, several causal factors were identified. The error was a result of both facility and human error. Mr. B, a 67-year-old patient, presented to the small, six-room, rural hospital ED due to severe pain in his left hip following a fall. In his quest for care, he came across some hurdles that eventually led to his death. Amongst one of the many issues that led to complications was the fact that the hospital was short staffed with only one RN, Nurse J., and one LVN on shift. There was also only one ED physician, Dr. T. At the time of Mr. B’s arrival, two other patients were being cared for. As Mr. B was being treated, a patient that was in respiratory distress was being admitted. Meanwhile, the two patients that had been seen earlier were

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