Organization Systems and Quality Leadership C489-Task Two Western Governs University

A. Root Cause Analysis The sentinel event in this scenario was directly related to the respiratory distress the patient experienced following a left hip reduction procedure requiring moderate sedation. A sentinel event is classified as any situation that causes injury or death and must be reported to the Joint Commission as well as have a root cause analysis completed. All RCAs are evidence-based driven. There are five steps to the Root Cause Analysis Method (RCA). The steps are; 1. Gather and manage data/evidence; 2. The problem statement, 3. Analyze Cause and Effect, 4. Solutions, and 5. Final Report. [ CITATION Con201 \l 1033 ] The following factors were significant contributors...