TASK 2 1
Organizational Systems and Quality Leadership
Task 2
Danielle Winchell
Western Governors University
This study source was downloaded by 100000827506713 from CourseHero.com on 02-16-2022 02:22:37 GMT -06:00
https://www.coursehero.com/file/18604280/Org-Systems-Task-2-Template/
, TASK 2 2
Organizational Systems and Quality Leadership Task 2
A. Root Cause Analysis
A root cause analysis (RCA) is “a systematic approach to understanding the cause of an
adverse event and identifying system flaws that can be corrected to prevent the error from
happening again.” (IHI). While assessing the case, study presented there are multiple causes
that contributed to the death of Mr. B which is in alignment to what the IHI states “Accidents
in health care almost never stem from a single, linear cause.”. (IHI). I will separate the
causative factors by errors and hazards.
The errors in this senior I believe are human causative factors that could have been
prevented. These errors are: understaffing and under-educated. It was obvious that in this
scenario that bother the physician as well as the RN were understaffed given the situation.
The physician was spread between 3 different patients and a critical incoming patient as well.
The RN also appeared to be spread among those patients. I believe the staff were under-
educated because they did not initially sedate the patient correctly and as time went on
continually sedated the patient which caused the medications to peak at different levels and
put the patient in respiratory depression. The LPN was assessing the patient post-procedure
but it does not appear that she was properly educated on conscious sedation. The patient
wasn’t also properly assessed and monitored post procedure, this could have allowed the RN
to recognize the patient going into respiratory distress and prevented the hypoxic brain injury.
The hazards in this scenario I believe are the causative factors that could not have been
prevented. The staff could not have anticipated the great influx of patients and the critical
This study source was downloaded by 100000827506713 from CourseHero.com on 02-16-2022 02:22:37 GMT -06:00
https://www.coursehero.com/file/18604280/Org-Systems-Task-2-Template/
Organizational Systems and Quality Leadership
Task 2
Danielle Winchell
Western Governors University
This study source was downloaded by 100000827506713 from CourseHero.com on 02-16-2022 02:22:37 GMT -06:00
https://www.coursehero.com/file/18604280/Org-Systems-Task-2-Template/
, TASK 2 2
Organizational Systems and Quality Leadership Task 2
A. Root Cause Analysis
A root cause analysis (RCA) is “a systematic approach to understanding the cause of an
adverse event and identifying system flaws that can be corrected to prevent the error from
happening again.” (IHI). While assessing the case, study presented there are multiple causes
that contributed to the death of Mr. B which is in alignment to what the IHI states “Accidents
in health care almost never stem from a single, linear cause.”. (IHI). I will separate the
causative factors by errors and hazards.
The errors in this senior I believe are human causative factors that could have been
prevented. These errors are: understaffing and under-educated. It was obvious that in this
scenario that bother the physician as well as the RN were understaffed given the situation.
The physician was spread between 3 different patients and a critical incoming patient as well.
The RN also appeared to be spread among those patients. I believe the staff were under-
educated because they did not initially sedate the patient correctly and as time went on
continually sedated the patient which caused the medications to peak at different levels and
put the patient in respiratory depression. The LPN was assessing the patient post-procedure
but it does not appear that she was properly educated on conscious sedation. The patient
wasn’t also properly assessed and monitored post procedure, this could have allowed the RN
to recognize the patient going into respiratory distress and prevented the hypoxic brain injury.
The hazards in this scenario I believe are the causative factors that could not have been
prevented. The staff could not have anticipated the great influx of patients and the critical
This study source was downloaded by 100000827506713 from CourseHero.com on 02-16-2022 02:22:37 GMT -06:00
https://www.coursehero.com/file/18604280/Org-Systems-Task-2-Template/
