C489 Task 2 Organizational Systems & Quality Leadership C489 Task 2; SAT1-1217 Western Governors University

A: ROOT CAUSE ANALYSIS (RCA)

The purpose of a root cause analysis is to understand the causes of an adverse event and identify system flaws that can be corrected to prevent the error from happening again (Ogrinc & Huber, 2018). A root cause analysis can be used to see where an error happened and what can be done to improve the situation. In this situation multiple preventable errors occurred, in which a patient ended of dying. Mr. B died because of improper protocols, lack of staffing and poor patient follow-up. In circumstance we need to learn from the unfortunate mistakes. 

A1: RCA STEPS The primary step is to identify the problem, why did it happen and how can it be...