ORGANIZATIONAL AND QUALITY LEADERSHIP

Organizational Systems and Quality Leadership
Task 2; SAT1-0517
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Organizational Systems and Quality Leadership Task 2; SAT1-0517
A. Root Cause Analysis
A root cause analysis is viewed as an approach that assesses the what, why, and how of an event to advance the safety of a given system. It puts into consideration the causes and errors that resulted in the occurrence of a sentinel situation (Jones & Despotou, 2016). As per the case study, the Sentinel situation was the death of a patient. The analysis focuses on decreasing errors rather than looking for parties to place the blame on.

A1. RCA Steps
The first step involves the identification of what occurred in an event. The second step consists in determining what is expected to have happened. The third step entails identifying the causes. The fourth step involves developing the causal statements while the fifth step consists of the identification of recommendations by the medical team (Jones & Despotou, 2016).
A2. Causative and Contributing Factors
The sentinel situation entailed respiratory arrest and the conscious sedation procedure. Some of the factors that led to the event include inadequate staffing, high patient ratio, and the patient not being monitored as expected. Other factors include the absence of supplemental oxygen before the procedure and alarms being disregarded by the members of staff.
B. Improvement Plan
There is the need to establish a commit…