Organizational Systems and Quality Leadership C489 Task 2 RCA and FMEA Western Governors University

A- Root Cause Analysis (RCA) The given scenario involves Mr. B, a 67-year-old man who fell at home and broke his hip and when taken to the hospital in order to get treatment ended up dying as a result of errors and safety violations from his care team. A RCA is a tool used to analyze an adverse event in order to find contributing factors and causes of errors that can be improved or prevented. According to the Institute for Healthcare Improvement (2018), there are six steps involved in the RCA process that are: forming a team, identifying what happened, determining what should have happened, determining causes and contributors, developing causal statements, and recommending actions....