C489T2.docx C489 Task 2: RCA and FMEA Western Governors University A.Root Cause Anal

C489T2.docx    C489  Task 2: RCA and FMEA  Western Governors University  A.Root Cause Analysis (RCA)  Root cause analysis is used to find an underlying cause of a problem through a multi-step process. When there is no easy fix one can consider the root cause analysis as an approach to problem-solving. In order to prevent the error from continuing one needs to identify the root cause of a problem to allow the opportunity to correct and prevent in the future.  1.RCA Steps  When an incident occurs a team of 4-6 people with all of the information gather to complete the RCA steps of which there are 6 used to search for the root cause of the issue. The following according to IHI are the RCA steps:   1. Identify what happened.   2. Determine what should have happened.   3. Determine causes – ask why five times.   4. Develop causal statements.   5. Generate a list of recommended actions to prevent the reoccurrence of the event.   6. Write a summary and share it.  2.Causative and Contributing Factors  A gentleman as identified by Mr. B is a 67-year-old male weighing approximately 79 kg presented with left hip pain to a small 6 bed emergency room. Upon arrival Mr. B stated he had a mechanical fall when he tripped over his dog. Mr. Bs vital signs were all within normal limits however he appeared to be tachypneic, likely due to pain he rated at a 10/10 on the pain scale. Mr. B had obvious shortening of his left leg some notable edema and ecchymosis with limited range of motion. His prior medical hi