Organizational Systems and Quality Leadership


Root Cause Analysis (RCA) is a structured method that is used by medical professions to analyze adverse and serious medical events. Initially, this method was developed to analyze industrial accidents, but today RCA is deployed in healthcare to analyze errors that might have led to serious medical happenings. A major tenet of RCA is to identify underlying problems that lead to an increase in the error occurring while avoiding factors that only lead one to focus on mistakes done by individuals. RCA consequently utilizes the frameworks method to recognize both dynamic errors (errors happening at the interface between complex systems and humans), and latent errors (the masked issues inside medicinal services frameworks that add to unfavorable occasions) (American Nurses Association, 2006). Notably, it is one of the most broadly used review strategies for identifying and detecting hazards in a healthcare setting.  RCAs follow a pre-specified protocol tool that starts with data collection and reconstruction of the event through a reviewing of records, as well as, interviewing those who were present when the event happened. This is what makes RCA one of the most important tools in the healthcare setting, as it takes measures to ensure that future harms are eliminated.

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

The main objective of conducting RCA in a healthcare setting is to audit Medicare claims, and determine areas where there are opportunities to correct systems to ensure that errors occurring in treating patients are eliminated (American Nurses Association, 2006). RCA can also be used to help improve hospital systems that are administrative in nature such as improving the coding system, as well as, storage of patients’ data to guarantee easy retrieval and privacy of patient’s records. 

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

The RCA process involves six detailed steps that act as a guide on the steps that should be taken when conducting the process. This six-step structured approach to the analysis of an incident makes it possible to ensure that all the causes of the incident are uncovered and addressed through appropriate actions.

Step 1 – Immediate Action and Identify Possible Causal Factors

In the event of an incident happening, the first step of action is taking immediate action that may involve cordoning the area where the incident has occurred, making the area safe, and preserving the scene to ensure that no major alteration happens to the scene. The investigators should also notify relevant parties and summon them to the area of the incident. It is important to mention that the accident investigation should begin at this early stage through the collection and preservation of evidence that may be contaminated.  To identify causal factors, investigators should ask the following questions:

  • What kind of sequence of events led to the problem happening?
  • What are the major conditions that allowed this problem to occur? 
  • What kinds of problem co-exist with the major problem and might have played a role in contributing to this problem? 

It is important to identify as many causal factors as possible. This is vital, as it would ensure all contributing factors are identified and resolved. 

Step 2: Plan investigations

The second step in this process is to plan for the investigations by determining the resources that will be required and the personnel that will help in resolving the issue. This is very important as it helps the lead investigator to determine what resources they will need in the investigations and prepare them in advance. This ensures that once investigations start, the process is continuous with no possibility of logistical challenges. 

Step 3 Identify the Root Cause

The third step would be to find the main or the causes of the health problem that has occurred.  Investigators have to start with the causal factors identified above and determine why these factors happened. Finding the root cause of a health problem can be very hard, as one should investigate deeper until all pertinent questions have been answered. There are some methods can be used to identify the root cause of a problem. One method for identifying root causes is through the construction of a root cause tree (American Nurses Association, 2006). This starts with the problem and then one does a brainstorm of all causal factors to help identify the root problem. 

Step 4 – Data Collection and data collection 

The information and data about the incident that happened are available from many sources. Investigators may get this information from all the people involved such as witnesses, nurses, and doctors. They may also turn to equipment, documents, and CCTV cameras from the scene of the incident. After data has been collected, it is vital to be able to analyze this data in order to come up with deductions that can help in making recommendations. Normally, an incident is not just an isolated event, but also a series of events that lead to the actual incident. Investigators need to understand these events before determining why the incident happened. 

Step 5 – Corrective Actions

Investigators should propose ways that if implemented the incident may not occur in the future. 

Step 6 – Reporting

This involves the conclusion of the investigation and it only happens when all outstanding issues have been closed out and findings communicated to the management. 

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

Step 1 – Immediate Action and Identify Possible Causal Factors

In this case scenario, it would be the duty of the investigators to determine what led to the events that led to the death of Mr. B. demise number of issues might have led to his demise such as the patient’s weight and current regular use of oxycodone. This made it hard for the nurse to sedate him. In addition, the lack of administering oxygen mask to the patient who should have been on a constant oxygen mask. 

Step 2: Plan investigations

In this stage, the investigators should sit down and determine how they will conduct their investigations. They should put in place a team consisting of people with qualified skills that will help determine the root cause of Mr. B’s death, as well as, what went wrong. 

Step 3 Identify the Root Cause

The third step involves determining the root cause of the incident. This step will uncover that lack of proper communication between the hospital and the previous institution where Mr. was admitted; on the importance of having an oxygen mask fitted on Mr. b at all times was the main reason why Mr. B died. 

Step 4 – Data Collection and data collection 

This step would involve interviewing Nurse J and the doctor to give their account on the measures they took and when admitting the patient, the procedures they performed, and the measures they took when the patient blood pressure went down and they lost consciousness. B’s son should also be interviewed as well as getting information from the patient’s hospital file. 

Step 5 – Corrective Actions

Here the investigators should recommend to the hospital the importance of having good communication at all times

Step 6 – Reporting

Here the investigators should recommend to the hospital the importance of having good communication at all time (Epstein & Turner, 2015). Admitting nurse should also get all the necessary information about a patient from the hospital they were admitted before being transferred to the hospital. 

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

Having a good communication system that takes into account all relevant information that needs to be communicated to all medical professions attending to a patient. 

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 process involves freeze-unfreeze-freeze stages. In this case, the first step would be introducing the new communication methods into the institution and then stopping to see its impact on the process, as well as, how the employees accept these changes. After this has been observed, the management should then allow new changes to take effect (American Nurses Association, 2006). 

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

The best way to test the proposed intervention is to put it in place and then analyze how it works. One should also see how comfortable employees are with the new system before deciding whether the new system is a success or a failure (American Nurses Association, 2006). 

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

Promoting quality care

Nurses are required to act as leaders in their workplace. It is important for a nurse to act as a leader and ensure that patients receive quality care. For example, they can always be making rounds in the wards to ensure that each patient has been attended to and that they have received high-quality medical care from other nurses. 

Improving patient outcomes

Improving outcomes is one of the major roles that nurses play to ensure that patients receive high-quality services. This can be attained by ensuring that all medical procedures are done effectively and at the right time (Epstein & Turner, 2015). It is vital to work with other nurses and doctors to ensure that all the services needed by the patient are performed at the right time. 

Influencing quality improvement activities

It is vital to work towards ensuring that procedures are improved all the time at the workplace. Nurses can make sure that they work with the hospital management team to ensure that they are provided with high-quality tools that can facilitate them in performing their work, which is offering high-quality services to their patients (Epstein & Turner, 2015). 

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

Having discussed the importance of RCA and FMEA procedures at the workplace to help reduce health incidents from happening, as well as, improving systems in the workplace, one can state that nurses that are involved in these procedures are showing a high level of leadership in their workplace (American Nurses Association, 2006). These procedures play an important role in shaping and reorganizing how hospitals are run, as well as, improve their systems. A person that is involved in these processes shows great leadership qualities that should be valued by the institutions they work. 


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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