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RTT1 Essay

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RTT Task 2 The provided scenario gives an account of a busy emergency department with competent staff, and the multiple errors that led up to the most severe error possible in healthcare, unnecessary death of a patient. A root cause analysis (RCA) can be utilized to help understand the systems at fault within the facility so that improvements can be determined and implemented to prevent any future occurrences (Cherry, 456). RCAs focus on systems rather than blaming individuals involved, therefore they are only appropriate in cases where there has been no willful negligence or criminal acts (Huber & Ogrinc, 2014). The overall purpose of RCAs is to find out the causes of the adverse event and determine how to keep similar errors from …show more content…

These statements link the cause to its effects and then back to the main event that promoted the root cause analysis (Huber & Ogrinc, 2014). Guidelines for writing causal statements include the need for clarity in the relationship, statements should use neutral language and not imply blame, cause should be given for any human error, and any violation of procedure should also have a preceding cause (Huber & Ogrinc, 2014). Recommendations for interventions for change must next be made for the process improvement process to be successful. Recommendations should meet the following criteria; they should be clearly linked to the identified root causes, recommendations should address all of the root causes, be designed to reduce the likelihood of reoccurrence and severity, and be clear and concise (Huber & Ogrinc, 2014). The acronym SMART is also helpful: Specific, Measurable, Achievable, Realistic, and Time measured. Once recommended changes are agreed upon the team can use the concept of change theory to decrease the likelihood of recent sentinel events similar to the example given. The IHI gives this definition on change theory “A change concept is a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement (IHI, 2004).” Recommended categories for change theory include simplification, elimination of waste, improve workflow, manage time, and change the work

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