Systems in an organization and good leadership Root Cause Analysis

Systems in an organization and good leadership
Root Cause Analysis
Errors and bad things that happen are a major cause of death and illness in healthcare today. When these bad things happen in healthcare groups, there needs to be an investigation to find out what went wrong and how to stop it from happening again. A root cause analysis (RCA) is a method used to figure out why bad things happen and to stop them from happening again. The RCA process looks back at a mistake to find flaws in the system that can be fixed to stop it from happening again. The main goal of an RCA is to figure out what happened, why it happened, and what needs to be changed to stop mistakes from happening again. When using this method, the healthcare worker should know that a good root cause analysis (RCA) lets them make a plan to fix the problem at its source.

A1. RCA Steps

In order to do a root cause analysis, you have to put events in order so you can figure out what happened and what needs to be fixed. The way an RCA is done is based on the fact that events in healthcare always have more than one cause, not just one straight line. The Institute for Healthcare Improvement (IHI) came up with six steps to help people figure out how to look at a healthcare problem.

Step 1: Figure out what went wrong

Step 2: Figure out what was supposed to have happened.

Step 3: Determine causes

Step 4: Develop cause statements

Step 5: Make a list of things that can be done to stop the event from happening again.

Step 6: Tell people what you found.

Step 1: Figure out what went wrong

When doing a root cause analysis, the first step is often to figure out what happened. The RCA team has to figure out what the problem is by looking around, asking questions, and doing research. Information about the situation can be gathered from healthcare workers, the surroundings of the patient or healthcare worker, and the systems involved. When gathering information about the healthcare problem, it is important to be fair and honest so that the real mistakes that led to the problem can be correctly stated. ( Institute for Healthcare Improvement, n.d.-a). Sometimes, the RCA team can draw flow plans to show what happened in a more concrete way.

Step 2: Figure out what was supposed to have happened.

Before figuring out what the problem is with healthcare, it is important to know what should have happened in a perfect setting. Hospital policies, processes, and practice guidelines are used to figure out what the best way would have been to stop the bad thing from happening. The RCA team should take the time to look at the situation, make a flowchart of the most likely course of action, and compare it to the wrong way of doing things that led to bad results. So, the RCA team chosen should have enough knowledge, skills, and experience to solve the problem successfully.

Step 3: Determine causes

Health problems can be caused by a number of things. During this stage, the RCA team figures out what happened before the problem and what specific reasons led to the bad thing that happened. It is suggested that the RCA team look for the most obvious causes of the problem and also try to figure out what other, less obvious causes might be at play. A fishbone diagram is a graphic tool used in healthcare to show the different reasons of certain effects. For example, things like patient characteristics, job factors, individual staff members, team factors, the work environment, organizational and management factors, and the institution’s context can all play a role in health care issues. (Institute for Healthcare Improvement, n.d.-a). It is suggested that the reasons be looked at five times, so that different people can give different answers about what’s going on.

Step 4: Develop cause statements

Causal statements are used to show how the main event that started the RCA process is connected to the causes and their results. The causal statements help show how the things that went wrong were caused by the things that went wrong. Also, the causal statements are used to show how the different teams or events that were part in the adverse event are related to each other. When making causal claims, flow charts and diagrams from the previous steps can be helpful. This step is important because it lets health care workers see how their actions led to a chain of other actions that led to bad things happening.

Step 5: Make a list of things that can be done to stop the event from happening again.

At this point, the RCA team should start making a list of things that can be done to stop a similar bad thing from happening again. When deciding which actions to take, the team should think about whether the chosen actions are strong, weak, or in between. For example, a strong action is more likely to stop an event from happening than a weak action is to solve the problem. When it’s necessary, the RCA team should work with other parties to come up with long-term changes that are likely to stop the problem from happening again. For example, one of the changes could be to change the backup systems, train the staff, make new rules, standardize the tools, or make the processes easier.

Step 6: Tell people what you found.

The last step of the RCA process is to share the results with other stakeholders. This is done by making a summary of the results and telling other stakeholders about it. The report should explain what went wrong, who was involved, and what can be done to fix the problem. This step is a chance to bring in key people to help drive the next steps in improving quality.

A2. What Caused It and What Made It Happen?

Step 1: Figure out what went wrong

The sentinel case scenario shows how mistakes in the care given to Mr. B, a 67-year-old patient, led to his death. The patient’s son took him to the ER after he fell and was later found to have a left hip dislocation. When the patient got to the ER, his medical history was taken, and he was set up for a small treatment that involved moving, repositioning, and aligning his hip by hand. At that time, Nurse J and Doctor T were both available to care for the patient in the ER along with other people who needed care. Diazepam and hydromorphone were used to put the patient to sleep before the operation. After the hip of the patient was successfully moved, realigned, and manipulated, the patient had trouble getting better. During recovery, the patient’s situation got worse because his vital signs weren’t being watched. He had to be resuscitated. Unfortunately, the patient died in another hospital after being sent there because he or she had brain death.

Step 2: Figure out what was supposed to have happened.

There are many things that went wrong with Mr. B’s care, which led to his death. First, the patient fell and was in a lot of pain, so at 3:30 p.m., she went to the health center. The patient’s breathing rate was 32 breaths per minute, and his or her blood pressure was normal. The first thing that should have been done was to help the patient feel less pain, which could also have helped the patient calm down. The doctor and nurse didn’t give the patient their full attention until 4:05 pm. At this point, I saw that the ER had more people who needed help, but there were only a few staff members there that afternoon. A backup plan should have been put in place to make sure there was enough staff to handle the busy ER.

Doctor T and Nurse J helped the patient get ready for the small surgery, which was to realign the hip. Before giving Mr. B high amounts of sedatives, which caused him to have trouble breathing in the later stages of care, a full drug history should have been taken. After the operation was done, the patient was only put in a blood pressure monitor, and his son was told to keep an eye on his recovery. The nurse should have made sure an ECG machine was hooked up, gave the patient air, and kept an eye on his vital signs until he was fully better. When the patient’s oxygen saturation level was 85%, the LPN turned off the alarm instead of giving the patient more oxygen. I am also sure that the patient’s life could have been saved if Nurse J had started CPR as soon as he realized the patient wasn’t breathing. Instead, the nurse called for the STAT CODE team, which came to begin CPR.

Step 3: Determine causes

In the sentinel event, the bad result for the patient was caused by several things that were blamed on the inefficiency of the healthcare workers. The first thing that led to the whole problem was not taking a full patient history to find out what medications were being taken and how they affected the present treatment. With a full list of the patient’s medicines, the nurse and doctor should have been able to give the right amount of sedatives for the process. The second reason for the bad effect is that healthcare workers in the ER didn’t do their jobs well, especially when it came to making sure the patient was safe after being oversedated. After learning that the patient’s use of oxycodone to treat pain at home slowed down the sedation process, the doctor should have told the nurse to closely watch the patient.

Another problem that led to bad patient results was not having enough health care workers. On that day, there were too many patients who needed care, and only a few staff members were there to give patients full care. I think not having enough staff made it hard to keep an eye on the patient. Another reason why the bad result happened was because the medical staff, especially the LPN, didn’t use good judgment. The LPN only turned off the patient’s alarm instead of giving the patient oxygen. Another reason for the bad result is that the healthcare teams didn’t work well together. For example, the breathing team was there, but they weren’t called in when the patient’s oxygen saturation went down.

Step 4: Develop cause statements

The patient came to the ER with a breathing rate of 32 breaths per minute, and the pain had to be taken care of. If the doctor had thought about how to treat pain, he would have known that the patient takes oxycodone at home. The nurse and the doctor didn’t get a full background of the patient’s medications, so diazepam and hydromorphone were used too much. From another point of view, the busy ER made it hard for the nurse and the doctor to wait calmly before giving the patient more sedatives. If there had been enough workers, it would have been easy to keep an eye on how diazepam and hydromorphone were working instead of upping the doses.

It’s best to keep a close eye on people coming out of sleep because the drugs can sometimes make it hard to breathe. After the surgery was done, the nurse didn’t hook the patient up to the EEG to check the heart rate and give extra oxygen until the patient was fully recovered. At some point, the patient started to feel bad, and it became hard for them to breathe, so they were given CPR. The LPN saw that the patient’s oxygen saturation was 85%, but she didn’t give the patient oxygen. As a result, the patient had trouble breathing and died a few days later from brain death. Lastly, Nurse J didn’t start CPR as soon as he saw that the patient wasn’t moving. Lack of oxygen to the brain, which led to brain death, was possibly made worse by the delay in resuscitation.

Step 5: Make a list of things that can be done to stop the event from happening again.

In the future, the sentinel event can be stopped if the following steps are done.

Before sedating a patient, a full medical background should be taken, including what medicines they are currently taking.
In the emergency room, the second plan should be used when the patient’s needs are more than what the staff can handle.
There should be mandatory education and training for nurses in the ER so that they know how to care for people who are sedated.
There should be plans in place to make sure that health care professionals can talk to each other and work together.
Improvement Plan

As part of the plan to improve quality in the organization, nurses will get more training, rules will be reviewed, and interprofessional collaboration will be encouraged. It will be important to check the qualifications of both nurses and doctors in the emergency room (ER) to make sure that everyone has been trained in emergency care and giving patients moderate sedation. These papers will need to be looked over so that training and education can be set up based on the gaps found. When the individual certificate is looked at, a plan will need to be made to teach and train ER staff on mild sedation to improve their skills and knowledge of patient care. Care for the patient before, during, and after sedation should be a big part of the teaching modules. The training should also cover how to use sedatives, why they are used, and which ones are best for different kinds of people.

In the future, the bad thing that happened can be fixed by having clear rules and guidelines for how the ER is staffed. To help people who need emergency care get good care, the number of patients to staff should be emphasized. For example, the nurse and the doctor who were involved in the sentinel event would have benefited a lot from having a back-up plan. The new policy will tell the staff when to call for help and when not to. As part of another plan to improve quality in the ER, a checklist will be used to make sure that important patient information is taken before sedation. Adding the plan to the EHR system can be an important way to make sure that both the doctors and the nurses do the right things.

Interprofessional teamwork will be the other way to improve how care is given to patients. Interprofessional collaboration means that different healthcare teams work together toward a shared goal. For example, the respiratory team that was available during the sentinel event should have been called to make sure the patient was put on air. Also, there wasn’t a clear way for the LPN, Nurse J, and Doctor T to talk to each other, which led to mistakes in patient care that led to the bad event.

B1. Theory of Change

Change is something that all groups, no matter how big or small, have to deal with. Kurt Lewin came up with one of the most important models for managing change that is still used today. The three parts of Lewin’s model are “unfreezing,” “change,” and “refreezing.” In the unfreezing stage, the status quo is broken down in order to get the company ready to accept new change. It means challenging workers’ beliefs, attitudes, and actions to make a strong change that will improve quality and safety. (Batrus et al., 2016). During this time, the main goal is to make people aware of how the way things are done now hurts the organization in some way.

The second step is called “moving” or “changing,” and it includes making the change into the new state. During the moving stage, new changes are put into place and the group has to deal with the new reality. To keep the workers from going back to their old ways, the moving stage needs constant communication, education, and reinforcement. (Batrus et al., 2016). During the moving stage, holding meetings and other educational sessions should help remember employees why the change is happening and how it will help them once it’s fully in place.

The third stage is the refreezing stage, which shows how the new change has become stable. During this stage, organizational charts, clear job titles, and policies that guide the new process are made. Efforts must be made to make sure that the change doesn’t get lost and is instead built into the culture of the company. Using rewards and giving comments can help make sure that a new change stays in place in an organization.

Lewin’s method for managing change will be used to help the company do better in the future. During the unfreezing stage, workers will need to talk about what happened that led to the bad outcome and how the new change will make things better for patients. The staff will also be told how important education and training are for improving their skills and understanding about how to care for patients who need to be sedated. You can use other similar examples to make sure the workers understand why the new change is needed in the company. During the moving stage, the new rules will be put into place in the emergency room. The first step will be to teach the emergency room staff about sedation and how to work well with other pros. The care of patients will be based on policies about mild sedation and the use of sedatives.

During the refreezing phase, the new changes will become part of the organization’s mindset. Training and education sessions will be set up in the ER to tell the doctors and nurses about sedation. Monitoring will help make sure that the new rules about drugs and staffing are followed. To back up the new change, healthcare workers who provide better care for patients in the ER can get a reward. Also, new workers will be told about the change, and as part of their training, they will take a program to help them relax a little bit.

The Main Goal of FMEA

The failure modes and effects analysis (FMEA) is a structured way to find possible flaws in the way a product or method is designed. (Institute for Healthcare Improvement, n.d.-b). Processes in healthcare companies are meant to improve quality, but sometimes they don’t get the results that are wanted. The FMEA process helps find, rank, and limit the failure modes that can cause waste or harm.

C1. FMEA Process Steps

The Institute for Healthcare Improvement (IHI) says that there are five steps to doing an FMEA.


Step 1: Choose a method to test with FMEA.

During failure modes analysis, it is important to choose a process to look at. So that work is easier and wrong analysis doesn’t happen, the chosen process should focus on one area. The IHI says that big, complicated tasks should be done in parts to get better results. For instance, the sentinel event FMEA is about sedating patients who are awake. This is a small area, and the FMEA team will be able to figure out what made the patient’s sedatives not work.

Step 2: Recruit a diverse team

A multidisciplinary method is needed to solve problems in health care today. This method is also used in the FMEA process, in which healthcare workers from different fields work together to look into a problem. The nurses, doctors, managers, and clinical nurse educators will all be part of the sentinel event multidisciplinary team. This team has everything it needs to figure out what went wrong and why, and to suggest a change in practice.

Step 3: Have the team write down all the steps.

During an FMEA, there needs to be a clear way so that the right decisions can be made. The team of people from different fields has to make a list of all the steps that will help the process. Sometimes, a few members of the diverse team can help come up with a plan for the next step instead of bringing in staff who aren’t as important. Flowcharts are suggested by the IHI as a way to see how the whole process works.

Step 4: Fill the table with people from different fields.

The fourth step is to make a list of failure modes and what might have caused them. The team of experts from different fields should work together to find small and rare things that are likely to cause a process failure. (Institute for Healthcare Improvement, n.d.-b). The IHI table has nine columns that talk about different parts of failure, such as the type of failure, its causes, its affects, how likely it is to happen, how bad it is, the risk profile number, and what can be done to prevent it.

Step 5: Use RPNs to plan how to make improvements.

RPNs are numbers that are given to risks based on how likely they are to happen, how likely they are to be found, and how bad they are. After giving the RPNs, the multidisciplinary team looks at the results and makes plans to improve the process based on what they found. If the failure mode is likely to happen, the reason is looked at and other things are thought about to make the changes stronger. To improve the failure modes, the methods need to be changed and other resources need to be used.

C2. Table FMEA

See the table below

Testing to see if

The PDSA cycle will be used to test interventions for this process. The plan-do-study-act cycle is a step-by-step way to see if a group needs to change. The cycle is made up of four steps that help evaluate a result and test it again. During the “Plan” phase, the goal is set and plans for the actions of the other phases are made. During the “Do” part, the plan is put into action, and the expected results and observations that could help the plan work are written down. During the “Study” phase, the results are looked at and compared to what was predicted. During the “Act” process, any changes that can be made to the initial plan for implementation are looked at. Changes can be made to fix mistakes or to make it easier to start a new run.

The PDSA cycle can be used to test an intervention that aims to teach medical staff in the emergency room about how to sedate patients who are still awake. The plan is to make a health education program for nurses and doctors in the ER about how important it is to get a patient’s information before putting them to sleep. Second, the clinical nurse trainer will make a course for all of the ED staff on how to use sedatives and care for patients who are only slightly sedated. The focus will be on the choice of sedatives, the right amount of each drug, keeping an eye on the patient after sleep, and keeping good records.

During the “Do” part, the ER staff will be taught about moderate sedation. There will be weekly meetings to make sure that everyone on staff goes to the training classes and that every part of caring for patients is followed. At this stage, a note will be made about how the healthcare worker reacts to the new change and what might need to be changed. During the “Study” phase, the new change will be watched and mild sedation in the ER will be tracked. Any bad things that happen because of the new change will be written down so that other solutions can be made. How the “Act” part goes will depend on how the whole cycle ends. If the education method doesn’t help patients get better, other steps will have to be taken.

Show that you can lead.

Bringing out the best. In many ways, nurses are in a better situation to improve the quality of health care. For example, professional nurses can plan and run quality improvement programs in the ER to reduce the chance that mistakes will lead to bad outcomes. For example, the professional nurse can help ER workers take classes that teach them more about moderate sedation and improve their skills in this area. The nurse leader helps to improve the level of care for patients by setting up these activities.

Improving patient results. Using evidence-based methods to guide the delivery of safe patient care can lead to better outcomes for patients. For example, it is known that interprofessional teamwork is important for helping patients do better. It is a technique that can help cut down on medication mistakes and make sure patients get care in a safe way. The nurse boss wants to come up with ways to improve collaborative care, which can help patients do better.

Having an effect on actions that improve quality. Quality care is the degree to which the health care services given to a person or a group of patients lead to the desired improvement in health. Professional nurses have a chance to improve quality by helping make decisions about health care policies. (Boamah, 2018). For instance, the nurse leader can be a part of the team that comes up with staffing rules for the hospital. The leader can also help nurses get their concerns about staffing and jobs heard by professional groups.

E1. Including the nurse in the RCA and FMEA processes

The RCA is a tool that helps healthcare groups look back at the events that led to patient harm or other unintended results and figure out how to fix the real problems. With this method, a team of people from different fields is chosen to help find the problem, figure out what should have happened, and come up with ways to stop problems from happening again. The professional nurse can be a part of the diverse team that looks into problems and comes up with a list of things to do to stop them from happening again. The nurse leader can also help choose the members of the process improvement team, which is made up of people from different fields.

The FMEA is a tool that companies use to figure out all the ways a process could go wrong. The nurse leader can play a big part in choosing the team that will look at how things work and help figure out how changes might affect the business as a whole. The nurse leader also works with other important people to plan what to do in case something goes wrong.


Batrus, D., Duff, C., & Smith, B. J. (2016). Organizational change theory: Implications for health promotion practice. Health Promotion International, 31(1), 231-241.

Boamah, S. (2018). Linking nurses’ clinical leadership to patient care quality: The role of transformational leadership and workplace empowerment. Canadian Journal of Nursing Research50(1), 9-19.

Friedman, A. L., Geoghegan, S. R., Sowers, N. M., Kulkarni, S., & Formica, R. N. (2017). Medication errors in the outpatient setting: Classification and root cause analysis. Archives of Surgery142(3), 278-283. DOI: 10.1001/archsurg.142.3.278

Institute for Healthcare Improvement. (n.d.-a). Patient safety 104: Root cause and systems analysis.Retrieved from

Institute for Healthcare Improvement (n.d.-b). QI essentials toolkit: Failure modes and effects analysis (FMEA). Retrieved from

Related Posts: