C489 Task 2

C489 Task 2 A1. Explain each of the six steps used to conduct an RCA, as defined by IHI. Step one in a RCA is to identify what happened. The information needs to be as accurate as possible and contain as many facts as possible. The goal is to provide full understanding of how the event occurred by reviewing all record and reports that are pertinent. No one involved in the original error should be involved in collecting data. Step two is determine what should have happened. Flowcharts and graphs are helpful in this step to determine the error by comparing current policy and procedures to what occurred.
Step three is determine the cause of the error. In this step all directly and indirectly contributing causes are reviewed. IHI recommends asking why often in this...