RUNNING HEAD: RTT1 TASK 2 1 RTT1 Task 2: Root Cause Analysis‚ Change Theory‚ FMEA‚ and Nursing Western Governors University RTT1 TASK 2 2 RTT1 Task 2: Root Cause Analysis‚ Change Theory‚ FMEA‚ and Nursing Root Cause Analysis (RCA) A root cause analysis (RCA) is an essential tool that can be used to examine and understand the ways in which systems fail as well as discuss those specific failures that led to a specific adverse event and potentially implement steps or behaviors to
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Analysis of Hewlett-Packard: The Flight of the Kittyhawk. Maggie Xu February 8‚ 2012 1. Background: The Kittyhawk Project. Hewlett Packard (HP) decided to produce 1.3-inch disk drives to become the market leader in a new market and increase HP’s revenue. Although the market for 1.3-inch disk drives was still unclear and still developing‚ HP decided to organize a special team to develop this new product. This group was multi-talented‚ with the best engineers from every department in the
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Write-ups—Hewlett-Packard: The Flight of the KittyHawk(A) Two years after launching the Kittyhawk in mid-1992‚ Rick Seymour‚ the Kittyhawk project leader‚ was facing a dilemma to continue the project with the three possible options or to recommend to abandon this project. Due to the comparatively small market share in disk-drive market‚ Bruce Spenner‚ the general manager of the Disk Memory Division‚ decided to enlarge Hewlett-Packard’s market share by launch an innovational product - Kittyhawk. However‚ plans
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To ensure the success of any business‚ several fundamental mechanisms must be addressed. These particular mechanisms are known to effect all businesses be they long established or recently formed. Upstarts are particularly vulnerable to these which are: managerial incompetence or inexperience‚ neglect‚ weak control systems‚ and insufficient capital. Methodology must be designed and implemented to address each of these issues. Managerial incompetence can be addressed through a comprehensive performance
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United Airlines Flight 232 On July 19‚ 1989‚ a McDonnell Douglas DC-10-10 operated by United Airlines experienced a catastrophic failure of the number 2 tail-mounted engine during cruise flight. The catastrophic failure led to engine debris severing all three flight control hydraulic lines resulting in total hydraulic loss. The pilots were subsequently unable to control the airplane‚ except by manipulation of the throttles to vary engine thrust‚ resulting in a crash landing. The NTSB determined
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A Root Cause Analysis Western Governors University Author Note Organizational Systems and Quality Leadership (RTT1) A Root Cause Analysis Healthcare facilities that are accredited by Joint Commission are required after a sentinel event to conduct a root cause analysis (RCA). A root cause analysis is conducted to determine the cause or factors that contributed to the sentinel event. A few things must be asked in the RCA such as who‚ what‚ where‚ why and how in order to identify
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properly investigate the situation in hopes to learn from the event and hinder another episode. The following will discuss procedures used to investigate sentinel events such as root cause analysis‚ change theory and failure mode and effects analysis using the scenario involving Mr. B in Task 2 instructions. A. Root Cause Analysis Nursing is a profession of helping others. Those who choose to work in healthcare never intended on harming. However‚ if harm does come to a patient proper policy and
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a) LOAN SYNDICATION – Rhodes 1996:13) defines a syndicated credit as a loan in which two or more banks (the syndicate) contract with a borrower to provide (usually medium term) credit on common grounds governed by a common document. One member of the group is normally appointed to act as the managing or lead bank for the syndicate and it is the role of this bank to coordinate all negotiations‚ payments and administration between parties once the contract has been executed.it is a multi - bank transaction
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NAIROBI STOCK EXCHANGE-LISTED COMPANIES For details on how to be listed‚ please see our NSE Listing Manual AGRICULTURAL Eaagads Ltd Ord 1.25 Kapchorua Tea Co. Ltd Ord Ord 5.00 Kakuzi Ord.5.00 Limuru Tea Co. Ltd Ord 20.00 Rea Vipingo Plantations Ltd Ord 5.00 Sasini Ltd Ord 1.00 Williamson Tea Kenya Ltd Ord 5.00 COMMERCIAL AND SERVICES Express Ltd Ord 5.00 Kenya Airways Ltd Ord 5.00 Nation Media Group Ord. 2.50 Standard Group Ltd Ord 5.00 TPS Eastern Africa (Serena) Ltd
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ROOT CAUSE ANALYSIS OF A SENTINEL EVENT Diane Swintek Western Governors University Root Cause Analysis of a Sentinel Event A root cause analysis (RCA) is a method by which we can examine a serious adverse event and identify the cause‚ or causes‚ that led up to the event. Although personnel are involved in these events‚ the primary purpose of the RCA is to identify the cause‚ not to assign blame (Agency for Healthcare Research and Quality‚ 2014). It is through identifying a cause‚ or
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