NSG C489 Task 2 Complete - Organizational System and Quality Leadership

Organizational Systems and Quality Leadership SAT Task 2

1

NCG C489 Task 2 Complete - Organizational System and

Quality Leadership

Organizational Systems and Quality Leadership

SAT Task 2

Rylee Schultz

Western Governors University

November 10th, 2020

2

Root Cause Analysis

A reactive process that occurs as the result of a problem is known as a root cause

analysis. Root cause analyses occur after falls, unexpected deaths, near miss events. Following

the event, you look for possible trends that may have caused the event, and create a plan to fix or

change things to prevent the event from recurring.

RCA Steps

After an event has occurred, a team must be formed to evaluate the problem. The team

should consist of staff from different areas of the organization. For example, a member of the

administration team, manager (s), and the caregiver that was involved with the event and the

patient involved or family members (Ogrinc and Huber, 2019).

The first step when conducting an RCA is to identify the failure in the process that caused

a problem. Collecting accurate information is essential in order to describe and identify what

happened Ogrinc and Huber, 2019).

The second step in the RCA process is to determine what should have happened with the

most ideal conditions. Reading over policy and procedures to see what should have been done

correctly to avoid the event from occuring helps guide the second step (Ogrinc and Huber, 2019).

The third step in the RCA process is to determine the factors that led to the event

happening. Factors can be direct causes or contributory factors (Ogrinc and Huber, 2019). The

team investigating the incident should ask themselves “why” several times (Ogrinc and Huber,

2019).

The fourth step involves writing a statement that is casual in nature and contains three

parts (Ogrinc and Huber, 2019). The statement includes the cause, effect, and the event.

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