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Organizational Systems And Quality Leadership (NURS 4210) C489 Task 2 Original

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Sandra Watson
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Western Governors University

Organizational Systems and Quality Leadership (NURS 4210)

C489 Task 2 Original – Passed with no revisions

Organizational Systems and Quality Leadership Task 2
Root Cause Analysis
Root cause analysis (RCA) is a systematic methodology utilized to study critical
detrimental incidences within the health care system. A primary perception of RCA is to
distinguish fundamental dilemmas that enhance the possibility of inaccuracies instead of fixating
on oversights made by a person (Patient Safety Network, 2019). An integrative panel of
individuals uses the RCA method to determine what transpired, why the events took place, and
how to avoid the incident from reoccurring. The group concentrates on the “how” and “why”
and not “who” (U.S. Department of Veterans Affairs, n.d.). By analyzing how and why the
event occurred will aid in preventing critical incidences in the future.
RCA Steps
Step One: Identify what happened
The group of individuals designated to investigate the incident determines what occurred in a
thorough and factual style. To understand the information more distinctly, the group of
individuals may create flow charts or pictorials to visualize the incident.
Step Two: Determine what should have happened
The group needs to establish what perhaps may have resulted in optimal circumstances. It is
beneficial to create a flow chart and with these findings and evaluate them alongside step one.
Step Three: Determine the causes
During this phase, the project group explores circumstances that precipitated the occurrence.
They analyze the most plausible and relevant details at this time. Several professionals propose
that RCA groups inquire to the why of the situation five times to arrive at an explanation

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Organizational Systems And Quality Leadership (NURS 4210) C489 Task 2 Original

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