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C489 Task 2 Organizational Systems & Quality Leadership C489 Task 2; SAT1-1217 Western Governor’s University A: ROOT CAUSE ANALYSIS (RCA) The purpose of a root cause analysis is to understand the causes of an adverse event and identify system flaws th

 

C489 Task 2 Organizational Systems & Quality Leadership

C489 Task 2; SAT1-1217

Western Governor’s University

 

A: ROOT CAUSE ANALYSIS (RCA)

 

            The purpose of a root cause analysis is to understand the causes of an adverse event and identify system flaws that can be corrected to prevent the error from happening again (Ogrinc & Huber, 2018). A root cause analysis can be used to see where an error happened and what can be done to improve the situation. In this situation multiple preventable errors occurred, in which a patient ended of dying. Mr. B died because of improper protocols, lack of staffing and poor patient follow-up. In circumstance

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