sentinel event of Mr. B, a sixty-seven-year-old patient presenting with severe left leg pain at the emergency room. A root cause analysis is necessary to investigate the causative factors that led to the sentinel event. The errors or hazards in care in the Mr. B scenario will be identified. Change theory will be utilized to develop an appropriate improvement plan to decrease the likelihood of a reoccurrence of the outcome of the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA) will be
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Leadership Task 2 Mark Woodard Western Governors University This paper will analyze the cause of the sentinel event which occurred to Mr. B, a sixty seven year old patient which presented to the emergency room with left leg pain. A root cause analysis will be necessary in this case to investigate the causative factors which led to Mr. B’s sentinel event. The factors in this unfortunate case weather they were errors in his care, or hazards in the system will be
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Organizational Systems and Quality Leadership Task 2 A. Root Cause Analysis The purpose of this root cause analysis is to carefully examine the causative factors, errors, and hazards that led to the sentinel event of Mr. B’s death. Mr. B was 67 year old male that presented to the ED with his son and neighbor. Mr. B stated that he tripped and fell over his dog. Upon assessment Mr. B’s vital signs were stable with the exception of rapid respirations, his left leg was shortened, red and swollen
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Root Cause Analysis Healthcare facilities that are Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredited are required to implement root cause analysis as part of their obligation. The root cause analysis team strives to assess and improve patient outcomes as specific situations occur by forming a team of experts that were involved in the situation. Cases are reviewed and processes are implemented to correct the errors that took place. Four key questions are asked, what
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A. Root Cause Analysis A root cause analysis (RCA) is a “systematic approach to understanding the causes of an adverse event and identifying system flaws that can be corrected to prevent the error from happening again” (Huber & Ogrinc, 2010). The root cause analysis is used to determine why the problem occurred in the first place and to identify the cause of a problem using a specific set of steps (Mind Tools, n.d.). The RCA team which consists of interprofessionals who are knowledgeable of the
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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)
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understand the patient and his needs better. This paper employs Root Cause Analysis approach together with the Failure Mode and Effect Analysis to determine the impact of the events that resulted in the death of a patient Mr. B. A. Root cause analysis The principal purpose of the Root Cause Analysis is to conduct an evaluation of the highest level of the problem to identify the actual cause. In the case scenario, the root cause analysis rules out the possibility of inadequate patient assessment as
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Root Cause Analysis Root Cause Analysis (RCA) is a process that pinpoints vital or root aspects that determine variation in conduct which includes the result or possible result of sentinel events. (Cherry, B., & Jacob, S. 2014). In the scenario with Mr. B., who was admitted to the Emergency Department (ED) after a fall with left leg and hip pain and was given conscious sedation for a hip reduction that resulted in respiratory arrest and subsequently cardiac arrest. There were several causes
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conduct a root cause analysis (RCA) in response to any sentinel event such as the one described below. Once the cause is identified and a plan of action established, it is useful to conduct a failure mode and effects analysis (FMEA) to reduce the likelihood that a process would fail. As a member of the healthcare team in the hospital described in this scenario, you have been selected as a member of the team investigating the incident. Scenario: It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old
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conduct a root cause analysis (RCA) in response to any sentinel event such as the one described below. Once the cause is identified and a plan of action established, it is useful to conduct a failure mode and effects analysis (FMEA) to reduce the likelihood that a process would fail. As a member of the healthcare team in the hospital described in this scenario, you have been selected as a member of the team investigating the incident. Scenario: It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old
Words: 1542 - Pages: 7
