Organizational Systems and Quality Leadership


Root Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA) are structured tools used in professional settings to analyze adverse systems and correct them, with the main objective of ensuring that systems are improved to avoid bad incidents from happening. These two systems use framework methods to recognize both latent and dynamic errors within a system with a bid to eliminate these errors and make systems much more effective and efficient. 

Explain the general purpose of conducting a root cause analysis (RCA)

In a healthcare setting, the main purpose why RCAs are conducted is to determine where there are flaws within a system with the main objective of correcting these flaws and ensuring that clients receive the best medical care possible. 

Explain each of the six steps used to conduct an RCA, as defined by IHI.

Step 1: –Identify Possible Causal Factors

The step will involve determining the causal factors. Investigators should look at all possible reasons as to why the event occurred and they can achieve this by asking themselves a number of equations that include:

  • What events led to this event occurring?
  • What are the main conditions that made possible for this event to happen?
  • Where there any kind of conditions that existed that may have led to the occurrence of this problem? 

Step 2: Plan investigations

The second step involves planning for the actual investigations. This step will see the investigators assemble all the required resources and personnel to help with investigations. 

Step 3 Identify the Root Cause

The third step would involve the actual investigation of the case and determine why the event occurred. Finding the real cause of the event can be very hard to manage. For this reason, it is very important for the investigators to work extra hard and careful to be successful in attaining the objective of the RCA process. 

Step 4 – Data Collection and data collection 

Data collection and analysis play a crucial role in solving the case. Data can be collected from interviewing the medical professions who handled the patient from the time they entered the hospital to the time of death. The son of the patient might also have information that can help in resolving the case, as they were present at the bedside of the patient most of the time. Data can also be collected from information that can be found from the patient’s file. After all this information has been collected, it will be the duty of the investigators to analyze it to determine what might have caused the death of the patient. 

Step 5 – Corrective Actions

After investigations have been completed, the investigators would be required to propose measures that if implemented may ensure that the event might never occur again in the hospital.

Step 6 – Reporting

This is when the investigators finish their work and have made some recommendations for the hospital management team to implement. 

Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome

Step 1 –Possible Causal Factors

The case will call upon the investigators to determine what brought about the death of Mr. B. This is a very important stage of the investigation because it determines the overall success of the RCA process.

Step 2: Plan investigations

This stage calls on the investigators to plan on how best they will conduct their investigations. They should come up with a team consisting of qualified personnel to help determine why Mr. B lost his life. 

Step 3 Identify the Root Cause

In this case, the root cause of the events is giving Mr. B wrong medication. He was also not provided with oxygen mask all the time due to his condition. 

Step 4 – Data Collection and data collection 

Data will be collected from the nurse, the doctor, and Mr. B’s son. Personal information recorded on Mr. B file will also provide a lot of information that can help in this investigation.

Step 5 – Corrective Actions

Here the investigators should recommend to the hospital the importance of having good communication at all times, as well as, taking care to ensure patients are not given wrong medications. 

Step 6 – Reporting

Patients should receive the right medication at all times. Special care should be made to ensure that patients with preexisting conditions such as allergy are not given medication that can make them ill or even cause death.  The hospital should have good communication at all time (Epstein & Turner, 2015). Employees in charge of admitting patients should be made to get all the necessary information from the hospitals their patients have been admitted before

Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome.

Having a system in place to ensure that no patient ends up being given the wrong medication. 

Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan.

This three-stage-change is one of the best strategies to implement change in an organization. Using this system, the new changes in hospital ensures that a patient’s history is analyzed properly in order to determine the allergies and other preexisting conditions are taken into consideration before medication is prescribed. 

D. Explain how you would test the interventions from the process improvement plan from part B to improve care.

To test this new system, I would put it in place and then analyze how it works. I would also train employees on how to use it to minimize errors. I would then analyze the results and determine if the new system should be shelved or implemented fully.

E. Explain how a professional nurse can competently demonstrate leadership in each of the following areas:

Promoting quality care

Leadership in nursing is important. Nurses can portray their leadership skills by ensuring patients receive quality care. 

Improving patient outcomes

Outcomes should be improved at all times to help improve the quality of services rendered to clients. This can be achieved by making certain patients receive medical service at the right time.

Influencing quality improvement activities

Improvement of activities is very important as it helps set up high quality standards that each profession at the work place should strive to attain at all times. Nurses ensure that they work with the management team to bring an environment that can guarantee clients receive the best Medicare possible (Epstein & Turner, 2015). 

Discuss how the involvement of the professional nurse in the RCA and FMEA processes demonstrates leadership qualities.

The advantage of using FMEA and RCA in a healthcare setting is that it helps reduce health hazards from happening as well as it helps improve on systems and processes in the health institution and this plays a major role in ensuring that clients receive high quality healthcare services (Epstein & Turner, 2015).


American Nurses Association. (2006). The American Journal of Nursing, 106, 15.

Catalano, J. T. (2015). Nursing now!: Today’s issues, tomorrow’s trends. Philadelphia, PA: F.A. Davis Company.Epstein, B., & Turner, M. (2015). The Nursing Code of Ethics: Its Value, Its History. Online Journal of Issues in Nursing, 20(2)

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