Organizational Systems and Quality Leadership Task 2

Organizational Systems and Quality Leadership Task 2 A. Root Cause Analysis The task directions for this prompt are to complete a root cause analysis that takes into consideration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s outcome). Review the IHI content on root cause analysis before beginning this task so that you are sure you understand the process. Then, simply follow the steps in the process. You can begin by briefly explaining what the RCA is. Generally, you do not need to go into great detail about the scenario: focus on what is important or has a direct impact on the outcome. While cause and effect and Ishikawa diagrams are visual representations of the relationships between the causative factors, their use is not mandatory in this assignment. It is better, generally, to describe in essay form what factors are involved, and how they are related. You will also want to clearly identify any errors (causative factors) and/or hazards (contributing factors) in the scenario. List these, together with an explanation of why you identified them as errors or hazards. I strongly encourage you to be very specific in which factors you are identifying as errors, and which as hazards. You might consider separating each into its own paragraph in your response. B. Improvement Plan The task directions for this ask you to discuss a process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario. Think about this paper as describing an ongoing cycle of activities surrounding the sentinel event. In the RCA you identify the causes of the problem, in this section you are offering a plan to correct those cause