NURS 4210 Organizational Systems And Quality Leadership

A. 1. Root Cause Analysis (RCA)

This section is going to highlight the purpose and importance of the Root cause analysis (RCA) of the incident happened with Mr. J. Once, the analysis will be completed the list of root causes will be identified and finally those root causes will be evaluated to implement several changes in the working culture of the hospital (Davis Giardina et al., 2013).

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Event Description

After a drastic fall and a right hip fracture, Mr. J was admitted in hospital, which was situated in a city of few Jewish people. That day, the food order for Mr. J was regular kosher chopped meat, however, the food supervisor mixed the order and mistakenly Mr. J was served with the chopped pork.

Chronology Of Events
J admitted to hospital after a fall and right hip fracture.
J ordered the food regular kosher chopped meat. However, the supervisor served chopped pork meat.
Her daughter came to know the incident and informed the physician and higher authorities.
Investigation Team

The investigation team consists of the Jewish physician and few higher authority representatives. They interviewed the food supervisor and the other departments to investigate the event.

Finding And Root Cause

It was found that the staff were not aware of nursing sensitive indicator and the prime reason behind it was negligence about the need of the Jewish community people.

Corrective Action

The corrective action of this fault should be training and education of the nursing staff regarding the needs of Jewish community.

B. 1. Improvement Plan

After this incidence, to make sure that such incidence never happens again, the entire nursing staff were interviewed to understand their knowledge about the Jewish community. The city in which this hospital was situated had very less amount of Jewish community and therefore, maximum of the staff were not aware of their cultural, social and food related preferences. Therefore, as per the corrective action of the RCA, the nursing staff should be provided with training and education sessions so that the staff become aware of the food and dietary habits of the Jewish community for future (Craft et al., 2012).

Change Theory

Lewin’s three-stage change theory model is a simple and effective model to implement changes and commonly termed as Unfreeze, Change and Freeze (Shirey, 2013). The following table describes the three steps in tabular form.

C. FMAE Model

This model is known as Failure model and effective evaluation. It is applied in this case because a team of investigators found out the flaws in the process and hence, evaluation becomes necessary (Paterno, 2012).



Review of the process

Ethical mistake in care for a Jewish patient and negligence about his dietary habits

Brainstorm potential failure modes

This negligence can lead to failure as the patients are complaining about such problems to the hospital authority

Potential effect of failures

Jewish will not prefer the Hospital in near future as their needs are being neglected consecutively.

Severity rankings

8 on a scale of 10

Occurrence ranking

7 on a scale of 10

Detection ranking

5 on a scale of 10

Calculate RPN


This table describes the seven steps of the FMAE model. The last four points, point out the severity, outcome detection and RPN of the incident happened. Former three are indicator of the issue happened in the hospital. Depending on the fourth RPN is calculated by multiplying the former three results. RPN stands for Risk Priority Number and the severity of the incidence is evaluated using this as a parameter. As the total RPN is in moderate level, the risk in the hospital has been calculated as moderate level.


Craft, D. L., Hong, T. S., Shih, H. A., & Bortfeld, T. R. (2012). Improved planning time and plan quality through multicriteria optimization for intensity-modulated radiotherapy. International Journal of Radiation Oncology* Biology* Physics, 82(1), e83-e90.

Davis Giardina, T., King, B. J., Ignaczak, A. P., Paull, D. E., Hoeksema, L., Mills, P. D., … & Singh, H. (2013). Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Health Affairs, 32(8), 1368-1375.

Paterno, F. (2012). Model-based design and evaluation of interactive applications. Springer Science & Business Media.

Shirey, M. R. (2013). Lewin’s theory of planned change as a strategic resource. Journal of Nursing Administration, 43(2), 69-72.