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Organization Systems and Quality Leadership Task 2 A. According to the Institute for Healthcare Improvement (n.d.), root cause analysis (RCA) is an organized approach to gather a further understanding of reasons of an adverse event and recognizing the

Organization Systems and Quality Leadership

Task 2

 

 

 

A. According to the Institute for Healthcare Improvement (n.d.), root cause analysis (RCA) is an organized approach to gather a further understanding of reasons of an adverse event and recognizing the systems imperfections that can be modified to avoid the error from happening again. The six steps that are used in root-cause analysis are: identify what happened, determine what should have happened, determine the causes (the 5 why’s), develop causal statements, generate a list of recommended actions to prevent the reoccurrence of the event, and write a summary and share it.

The incident that happened with Mr. B is a perfect example of a scenario that can use a root-cause analysis. Mr. B was left alone after being given moderate sedation. Although a continuous blood pressure monitor was attached to the patient, an ECG or pulse oximetry was not attached to

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