A. Explain the general purpose of conducting a root cause analysis (RCA).
- Explain each of the six steps used to conduct an RCA, as defined by IHI.
- Apply the RCA process to the scenario to describe the causative and contributing
factors that led to the sentinel event outcome.
B. Propose a process improvement plan that would decrease the likelihood of a
reoccurrence of the scenario outcome.
- Discuss how each phase of Lewin’s change theory on the human side of change
could be applied to the proposed improvement plan.
C. Explain the general purpose of the failure mode and effects analysis (FMEA)
- Describe the steps of the FMEA process as defined by IHI.
- Complete the attached FMEA table by appropriately applying the scales of
severity, occurrence, and detection to the process improvement plan proposed in part B.
Note: You are not expected to carry out the full FMEA.
D. Explain how you would test the interventions from the process improvement plan
from part B to improve care.
E. Explain how a professional nurse can competently demonstrate leadership in
each of the following areas:
� promoting quality care
� improving patient outcomes
� influencing quality improvement activities
- Discuss how the involvement of the professional nurse in the RCA and FMEA
processes demonstrates leadership qualities.
F. Acknowledge sources, using in-text citations and references, for content that is
quoted, paraphrased, or summarized.
G. Demonstrate professional communication in the content and presentation of your
Running Head: RCA, FMEA and their application 2
Organizational Systems and Quality Leadership
Principles of leadership should be applied to promote high quality health care in different
settings and environments. Theoretically, principles should also be applied for effective
applications of quality improvement process intended to achieve optional healthcare outcomes
and initiating safety (Shaqdan et al, 2014).
Purpose of Conducting a Root Cause Analysis (RCA)
A root cause analysis is an approach that involves seeking understanding of causes of
adverse occurrences in a particular setting or environment while error analysis is a tool that seeks
to identify, profile and analyze sources of faults as well as their potential consequences. RCA
cannot be carried out in a situation where the error was international. RCA uses a system
approach to the error, where it looks at the circumstances that would have caused the error. It
also uses engineering technique and similar critical technique which is similar to critical incident
technique. It is a problem solving approach focused on identifying and understanding underlying
causes of incidents and their potential aftermath (Shaqdan et al, 2014).
RCA also establishes trends that could be used to avoid or stop an event from occurring
whenever a human error is suspected. Improvements are then to be implemented to reduce the
risk of the human error from occurring or reoccurrence. Root cause analysis should be performed
as soon as the event to be analyzed has occurred. All parties should also be active so as to avoid
speculation. Whereas it could be inevitable that incidents could occur, RCA seeks to explore
various factors that lead to such occurrences with the purpose of mitigating impact or completely
avoiding occurrences and possible reoccurrences. Incidents can be potentially very expensive
Running Head: RCA, FMEA and their application 3
and their reoccurrence can have a massive financial impact on companies as well as third party
dependents in the event of a loss of human life (Shaqdan et al, 2014)..
Steps Used to Conduct an RCA as Defined By IHI
An ideal RCA team should consist of about six people from different professions so as to
achieve varied perspectives and experiences. Individuals, of all levels, with fundamental and
great knowledge and experiences of these occurrences should be included in an RCA Team. The
steps of RCA are (Kritsonis, 2005):
Step 1: Identifying what happened
The first step that the team should assess the various activities and actions that happened
during the event’s occurrence. The RCA team collects and collates information regarding how
the event happened as they profile the leading factors. The team could use some tools such as
simple flow charts that simplifies what happened in a particular setting (Kritsonis, 2005).
Step 2: Determine what should have happened
The team should then determine what could have happened if the conditions were ideal.
They can draw a flow chart of the ideal conditions and make a comparison between the events
with ideal conditions and the original event that occurred.
Step 3: Determine causes
This is where the team asks questions about the event. The team then determines the
factors that could have caused the event or incident to occur. The team should look at the direct
and indirect causes of the event. The team could ask the ‘ask why five times’ questions to
determine the root cause of the event.
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Step 4: Develop causal statements
The causal statements link the event, causes as well as the main reason(s) why RCA was
carried out. The causal statements help the team to explain how contributory factors about the
conditions would contribute to bad outcomes for patients and staffs.
Step 5: Generate list of recommendations that would help the event from occurring again
The team then should come up with a list of recommendations that they think would
prevent the event from occurring again and preventing suspicion of its occurrence or
reoccurrence in the future. The main recommendations often fall in these categories; Use of
backup system, standardization, software improvements, avoiding making common mistakes and
offering enlightenment to the staff.
Step 6: Writing a summary and sharing it
In this step the team clarifies the events that occurred and shares their hypothesis to
enable other experts to analyze it and make some improvements on the same.
Application of RCA Process to a Scenario
RCA is applied to help describe the causative and contributing factors that led to the
occurrence of the error. A successful RCA should ultimately lead to a proposal of an improved
process that will decrease the chances of the reoccurrence of the scenario outcome. Improving a
process does not just involve fixing the problem, learning about an occurrence and establishing
ideas that could improve status of situations. It involves improving the quality, productivity and
Running Head: RCA, FMEA and their application 5
making processes better. Factors to consider while improving processes include: effectiveness,
efficiency and adaptability (Kritsonis, 2005).
Mr. B dies from brain death after the family advises that the life support be removed.
This is after a series of tests and activities that led to his transfer from the rural hospital to a
If the conditions were ideal, the patient would have been thoroughly tested and diagnosed
to establish his actual health status. Upon establishment of his health condition, he could have
been immediately recommended to transfer to a different hospital.
What caused the death of Mr. B? Are there factors that made his death resulted in the
death. The lack of a comprehensive diagnosis and tests contributed to Mr. B’s death.
Did the number of nursing staff contribute to Mr. B’s death? Did the diagnosis play a part
in the death of Mr. B?
The following are some of the recommendations following the sentinel event of the death
of Mr. B:
Mr. B should have been thoroughly assess and examined
Running Head: RCA, FMEA and their application 6
The patient’s history of medical conditions could have been established on the day he
was admitted at the rural hospital
The patient should have been immediately transferred to the tertiary hospital and
emergency admission and treatment.
Process Improvement Plan
This is a plan that entails processes involving steps and action decisions during and after
the completion of a specific task. The process that is identified is the process of patient
comprehensive diagnosis with the overall objective of ameliorating the process such that death
incidents can be mitigated. A team of the right people is created to embark on the task of
achieving the overall objective. The team is then briefed and facilitated with requisite resources.
The process under review is then described while highlighting challenges and steps of activities.
The data is collected from study the diagnosis process under review. Then the team seeks further
understanding of the weak points of the processes under review. At this point the team is
expected to have established all the gaps. The team should then develop a plan for implementing
the various proposed changes. The new processes are the put to test by all the hospital staff as
per the recommendations of the process review team. After assessing the new processes as well
as responses, then the team can compile a final report (Kritsonis, 2005).
How Phases of Lewin’s Change Theory on the Human Side of Change could be applied to
the Proposed Improvement Plan
Kurt Lewin is widely considered as the father of change improvement with his ‘changing
three steps’ which uses ‘classic’ approach for managing change. According to Kurt, the first step
of changing a process is by unfreezing all the existing conditions. Unfreezing is done to reduce
resistance from the individuals. It can be achieved through; increase forces that can direct
Running Head: RCA, FMEA and their application 7
behavior away from existing situation, decrease restraining forces that negatively affect the
situation as well as finding activities that can assist in unfreezing. Lewin also suggested that
reinforcement of new patterns should be created. Lewin’s theory can be used to guide and ensure
success of the above proposed improvement plan. It helps to manage humans involved in the
change process (Kritsonis, 2005).
Purposes of Failure Mode and Effects Analysis (FMEA) Process
Errors will always occur and are not necessary easy to avoid. Effects analysis process is a
technique or tool for identifying necessary occurrences that could cause errors as well as
identifying techniques to prevent the errors from occurring or reoccurring. Potential failures,
problems and errors could be avoided through this process. This method can be used to evaluate
alternative process and procedures that could be used to avoid suspected errors and to monitor
changes that occur over time (Kritsonis, 2005).
It also entails methodology that could facilitate an improvement in several processes. It is
a tool that identifies and eliminates concerns and suspected errors to occur in a developing
process. The goal is to improve internal and external customer satisfaction. FMEA focuses on
prevention rather than fixing the problem after its occurrence. FMEA may be required by an
applicable quality management system standard. FMEA is a structured approach to estimate risk,
prioritize actions to be taken, evaluate design of validation plan and identifying the ways
(Cummings et al, 2016).
Purposes of failure mode includes identification of areas that could impact customers the
most as well as what could cause a problem failure and how the failure could occur and points
out on process failure that is most difficult to detect (Cummings et al, 2016).
Running Head: RCA, FMEA and their application 8
When FMEA should be conducted
I. FMEA should be conducted during a design of a new process or product
II. It should also be conducted when there is an improvement in a certain investigation
III. When a new design is used in new applications
IV. When a process or design that had existed earlier and was being used has been changed
V. Before selection of a specific hardware that would be used to manufacture
Steps of the FMEA Process as defined By IHI
FMEA procedure include;
I. For each process input determine ways in which the input could go wrong
II. For each failure mode, determine effects of the event
III. Identify potential causes of failures
IV. List current control causes
V. Calculate the risk priority number
VI. Develop recommended actions, assign responsible persons and take action
VII. Assign the predicted severity (Kritsonis, 2005).
Running Head: RCA, FMEA and their application 9
Steps in the
Failure Mode Likelihood of
dispensed to a
1 2 9 18
doctors fail to
is ailing a
4 3 10 120
Nurses fail to
time to a
6 2 9 162
Staff fatigue 6 3 7 126
5 7 8 280
Running Head: RCA, FMEA and their application 10
Testing the Intervention from the Process Improvement Plan
I would first plan the test and observe by including a plan for collecting data. I would
then try out the test on a small scale. I would then set aside time to analyze the data and study the
results. I would then refine change, based on what was learned from the test. I would then
evaluate the quality of the improvement interventions as well as the quality of the test (Kritsonis,
Leadership Demonstration of Professional Nurses
Nurses can demonstrate their leadership capabilities in promoting quality care by
effectively ensuring that resources and manpower are allocated in treatment facilities to achieve
optimum care. They can also achieve this by effective and efficient planning and implementation
of nurses’ work shift schedules as well as ensuring the requisite staffing levels that can give
patients the best possible attention and care (Williams, 2001)
They can also demonstrate leadership in improving patient outcomes through
ensuring that there is effective communication between the patients and the paramedics so that
the patients are treated appropriately and in a timely manner (Williams, 2001)
Nurses can also show leadership in influencing quality improvement activities by
ensuring regular or periodic in-work trainings. These trainings can ensure that nurses are
adequately equipped with latest and emerging trends and technological changes. They could also
additionally ensure nurses have access to information and technology so that they could improve
on their skills (Kritsonis, 2005).
Running Head: RCA, FMEA and their application 11
How Professional Nurse in the RCA and the FMEA Process Demonstrates Leadership
Nurses in the RCA and FMEA are proactive and do accept the status quo. They help in
improvement plans, interventions and the play a critical role in ensuring quality care.
Professional nurses taking part in the RCA and FMEA improve their integrity, accuracy and the
make the processes more comprehensive (Williams, 2001)
Running Head: RCA, FMEA and their application 12
Cummings, S., Bridgman, T., Brown, K., (2016). Unfreezing Change as Three Steps:
Rethinking Kurt Lewin’s Legacy for Change Management.