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Quality Leadership (NURS 4210) Organizational Systems Task 2

Sandra Watson
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Western Governors University

Organizational Systems and Quality Leadership (NURS 4210)

In this paper we will be analyzing an unfortunate sentinel event from the given scenario.
The patient Mr. B, a 67 year old male, presented with severe left leg pain to the emergency
department. Patient safety and well-being is always the highest priority. However, there are some
adverse outcomes that can take place and result in a sentinel event. Sentinel events are events
that result in death or serious physical or psychological injury. These types of events require
immediate review and analysis. A root cause analysis (RCA) is used to to investigate the factors
that caused the said event. We will be identifying factors, errors, and/or hazards that led to Mr.
B’s death using RCA. The development and discussion of a process improvement plan will be
presented in this paper as well. Change theory will be used to implement the plan. A failure mode
and effects analysis (FMEA) will provide recommendations for prevention of the similar events
in the future.
a. Root Cause Analysis (RCA).
Root Cause Analysis (RCA) – a tool that is used to identify the cause of the sentinel
event. It is designed to identify “the basic or causal factors that underlie variation in
performance, including the occurrence or possible occurrence of a sentinel event” (Cherry &
Jacob, 2011, p. 442). RCA identifies what and how the said event occurred and the reason why it
happened. It focuses on processes, events, and systems overall. Examination of the contributing
factors and causes of an error will be reviewed to help to prevent it from happening again in the
The Institute for Healthcare Improvement (IHI) outlines a series of steps for RCA
process. Usually, the team consists of 4-6 people involved in the case. In the given scenario, the
participants during the RCA were Dr. T., LPN and RN (Nurse J.), ED nurse manager, and the
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chief nursing officer. Other team members should i



Quality Leadership (NURS 4210) Organizational Systems Task 2

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