D1 Root Cause Analysis
Organizational Systems and Quality Leadership Task 2
Western Governors University
03/15/2015
Root cause analysis (RCA) is one of the organized techniques that can be used as an analyzer in any events of adverse events. In health care settings the best method to track down an adverse event and find out the root cause of the problem, would increase the overall patient well-being outcome. The best approach to an adverse event would be to set up questions systematically from the point of start till the end of the given service in order to detect the safety risk factors.
In the given scenario, root cause analysis technique will be used to detect the errors that happened during the emergency department admission …show more content…
of Mr. B who with the chief complain of severe left leg and hip pain secondary to fall.
A. Root Cause Analysis
“The Joint Commission requires that organizations conduct a root-cause analysis to identify contributing factors within 45 days of a sentinel event or becoming aware of the event. This analysis focuses on systems and processes, not individual performance. All persons involved with the event in any way should participate in the analysis, as each may have important insights and observations.” Sorbello, B. (2008, October 11 )
According to the mentioned Scenario Mr. B, a sixty-seven-year old gentleman,who admitted to Emergency department with stable blood pressure and heart rate and excrutiating pain of the Left leg and Hip area.
Based on the given scenario patient received extra doses of sedating receiving all the administered pain medications given to patient had a side effect of respiratory rate slow down and respiratory distress and failure. Furthermore, the amount of given medication was not followed by hospital protocol. Furthermore, after manual procedure of Left leg and hip relocation, there was no given order of Supplemental oxygen for the patient prior and after procedure and no EKG monitoring of the heart was mentioned throughout the scenario.
Even though MD ordered continues monitoring of patient’s oxygenation status and the blood pressure level status , but there were no orders to monitor respiratory rate status.The other error during the scenario is the knowledge defecit level of the LPN, whom just scilenced the alarm for the oxygen saturation level in patient’s room without any further discusions or informing of assigned RN. On the other hand, the other factor of care failure was the ER department under staff situation which ended to ill-treatment of Mr.B.
B:
The change of the following scenario to prevent the sentinel event occurrences would be for the ER staff to follow up hospital protocol regarding the sedation. Secondly, Health care staff must have monitored patients vital signs status from admission to the discharge point.
LPN should have proper understanding of signs and symptoms of respiratory status post conscious sedation procedures, knowledge regarding sedative medication side effect and the adverse reactions and how to respond accordingly to such adverse reactions. Furthermore, there should be a proper communication among the healthcare providers for ultimate care outcomes. During conscious sedation procedure, there should have been constant checking and reassessing the cardiac and respiratory status of the patient by the staff. Additionally, During the work shift there should be acceptable number of float nurses in the emergency department to provide care during the shift.
Outcome Measure:
What are the factors that will be considered, monitored, observed, supervised, and verified? Proper and sufficient training of health care staff based on protocols and policies of the hospital agreement, in emergency department.
How the cases will be monitored and the patient’s charts and tests and lab results and plans will be accompanied? The monitoring and observation for the period of three months, in order to achieve the 100% compliance and to accomplish the adequate training and education of the staff per hospital policies and protocols.
How often they will revise? For three months every week
How long the measurement will be performed? For the period of three months.
What is the estimated compliance level to achieve during the three months? Must be 100% of estimated compliance level be attained.
How the test result will be verified? The test result should be reviewed accurately by the management of the risk and emergency department.
Discussion and Compliance:
C. (FMEA) Failure Mode and Effects of Analysis
Teams use FMEA to estimate processes for conceivable failures and to prevent them by correcting the processes proactively rather than reacting to adverse events after failures have occurred. This emphasis on prevention may reduce risk of harm to both patients and staff. FMEA is particularly useful in evaluating a new process prior to implementation and in assessing the impact of a proposed change to an existing process. Institute of Healthcare Improvement (2015, January 1).
Identification of team members in FMEA process in the mentioned scenario would be as following: The chief nursing officer, the unit nurse supervisor , the admitting ER doctor, nurse J , the LPN and the unit secretary. It would be the ultimate goal to involve all the staff members of this process in order to educate, evaluate and intervene efficiently. This grants a substantial chance to progress patients protection and well-being in order to advance team routine care during direct patient care process.
C1.
In first place, the team should undergo a thorough supervision process of six months period. The measurement of all the compliances of team members should be processed and supervised.The well-organized interferences in this scenario would be well informed staff using proper communication utilizing SBAR to notify physician in charge regarding patients’ condition. Appropriate training of team members in the technique of conscious sedation , by following hospital standard protocols.
The unit must develop and create a work environment that the staff motivated to work together and also help each other constantly to prevent from occurring of any errors, and if any errors happen they freely report the incident detailed early enough to configure a solution to solve the problem as a team.
There must be an implemented of the safe medication administration by a double checking of the high risk medication to prevent any over dose administration of medications to the patient. It should be standard policy enforcement regulation in the matter of the proper stocking of the rooms with the functional equipment such as: oxygen, suction, gloves, masks, etc by the staff to ensure the safe and prepared environment in the case of emergency in the Emergency Department. It would be necessary to constantly evaluate the system to ensure that there are no kinks, and if there is any so the necessary changes can be made. Implementation of the intervention will generate a system which is more unified and it is based upon the effective and proper training and communication among the staff to practice in their duty in order to maintain the highest safety in care of the …show more content…
patients.
C2. Pre-Steps
In order to place the successful implementation of the new system, first it must be analyzed.
In the FMEA pre-steps the team must be identified and the team members should list the failures which can occur in the system. The team must anticipate the effect and recognize by prioritizing the interventions in the areas with the greatest concern those with the one of the most significant effect. After prioritizing the failures in the system, the team must address the failures which have the greatest concern. Prior to the quality effort improvement, the data is evaluated regarding the medication administration during the conscious sedation procedure in order to be able to compare the before and after result. The evaluated data should include both positive and negative sides of the process and also the outcome of the process before and after the quality effort improvement process.
C3. Three Steps
FMEA is a process that has three steps “Each failure mode has a potential effect and each potential effect has a relative risk associated with it. The relative risk of failure and its effects is determined by three factors: severity, occurrence, and detection” (ICMA, 2014). Each factor in three steps of FMEA is rated on a scale of one to ten numbers, with the number ten being the most significant. Severity is a factor which is the consequences of the each failure mode that happens. For instance, never events, and patient harm, that would result from each failure mode if it did in fact take
place. In the case of Mr. B the severity was the event of patient death, which was considered the final outcome in the scenario after the result of the system failure. The second factor in the three steps of FMEA is the Occurrence which refers to the assessing the likelihood of the risk involved and the likelihood of the process that the failure can happen. In the Mr.B case by referring to the occurrence factor and knowing that the conscious sedation medication administration errors could have happened, it could have helped the staff to double check the medication before administration and also it could have helped them to have the proper training before the conscious sedation medication administration, to prevent any life threatening event, and minimizing the risk.
The third factor of the three steps FMEA is the detection, meaning if the failure occurs will we know it? Detection factor refers to the reorganization of the cause and the failure mode before it cause harm to the patient. In the Mr.B case the detection factor would have benefited the patient by recognition of the system failure prior of his status changes from bad to worst.
D. Nurses Roles:
Nurse J could have prevented the incident from happening, if she could have pursued the proper protocol in regards to conscious sedation, by close monitoring and reassign the patient status and the respiration and also the cardiac ECG. Also she could have stopped the incident by the proper communication among the supervisor in charge and the physician on the unit.
References
Sorbello, B. (2008, October 11). Responding to a sentinel event - American Nurse Today. Retrieved February 15, 2015, from http://www.americannursetoday.com/responding-to-a-sentinel-event/
Institute of Healthcare Improvement (2015, January 1). Retrieved February 15, 2015, from http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx
Western Governors University
03/15/2015
Root cause analysis (RCA) is one of the organized techniques that can be used as an analyzer in any events of adverse events. In health care settings the best method to track down an adverse event and find out the root cause of the problem, would increase the overall patient well-being outcome. The best approach to an adverse event would be to set up questions systematically from the point of start till the end of the given service in order to detect the safety risk factors.
In the given scenario, root cause analysis technique will be used to detect the errors that happened during the emergency department admission …show more content…
of Mr. B who with the chief complain of severe left leg and hip pain secondary to fall.
A. Root Cause Analysis
“The Joint Commission requires that organizations conduct a root-cause analysis to identify contributing factors within 45 days of a sentinel event or becoming aware of the event. This analysis focuses on systems and processes, not individual performance. All persons involved with the event in any way should participate in the analysis, as each may have important insights and observations.” Sorbello, B. (2008, October 11 )
According to the mentioned Scenario Mr. B, a sixty-seven-year old gentleman,who admitted to Emergency department with stable blood pressure and heart rate and excrutiating pain of the Left leg and Hip area.
Based on the given scenario patient received extra doses of sedating receiving all the administered pain medications given to patient had a side effect of respiratory rate slow down and respiratory distress and failure. Furthermore, the amount of given medication was not followed by hospital protocol. Furthermore, after manual procedure of Left leg and hip relocation, there was no given order of Supplemental oxygen for the patient prior and after procedure and no EKG monitoring of the heart was mentioned throughout the scenario.
Even though MD ordered continues monitoring of patient’s oxygenation status and the blood pressure level status , but there were no orders to monitor respiratory rate status.The other error during the scenario is the knowledge defecit level of the LPN, whom just scilenced the alarm for the oxygen saturation level in patient’s room without any further discusions or informing of assigned RN. On the other hand, the other factor of care failure was the ER department under staff situation which ended to ill-treatment of Mr.B.
B:
The change of the following scenario to prevent the sentinel event occurrences would be for the ER staff to follow up hospital protocol regarding the sedation. Secondly, Health care staff must have monitored patients vital signs status from admission to the discharge point.
LPN should have proper understanding of signs and symptoms of respiratory status post conscious sedation procedures, knowledge regarding sedative medication side effect and the adverse reactions and how to respond accordingly to such adverse reactions. Furthermore, there should be a proper communication among the healthcare providers for ultimate care outcomes. During conscious sedation procedure, there should have been constant checking and reassessing the cardiac and respiratory status of the patient by the staff. Additionally, During the work shift there should be acceptable number of float nurses in the emergency department to provide care during the shift.
Outcome Measure:
What are the factors that will be considered, monitored, observed, supervised, and verified? Proper and sufficient training of health care staff based on protocols and policies of the hospital agreement, in emergency department.
How the cases will be monitored and the patient’s charts and tests and lab results and plans will be accompanied? The monitoring and observation for the period of three months, in order to achieve the 100% compliance and to accomplish the adequate training and education of the staff per hospital policies and protocols.
How often they will revise? For three months every week
How long the measurement will be performed? For the period of three months.
What is the estimated compliance level to achieve during the three months? Must be 100% of estimated compliance level be attained.
How the test result will be verified? The test result should be reviewed accurately by the management of the risk and emergency department.
Discussion and Compliance:
C. (FMEA) Failure Mode and Effects of Analysis
Teams use FMEA to estimate processes for conceivable failures and to prevent them by correcting the processes proactively rather than reacting to adverse events after failures have occurred. This emphasis on prevention may reduce risk of harm to both patients and staff. FMEA is particularly useful in evaluating a new process prior to implementation and in assessing the impact of a proposed change to an existing process. Institute of Healthcare Improvement (2015, January 1).
Identification of team members in FMEA process in the mentioned scenario would be as following: The chief nursing officer, the unit nurse supervisor , the admitting ER doctor, nurse J , the LPN and the unit secretary. It would be the ultimate goal to involve all the staff members of this process in order to educate, evaluate and intervene efficiently. This grants a substantial chance to progress patients protection and well-being in order to advance team routine care during direct patient care process.
C1.
In first place, the team should undergo a thorough supervision process of six months period. The measurement of all the compliances of team members should be processed and supervised.The well-organized interferences in this scenario would be well informed staff using proper communication utilizing SBAR to notify physician in charge regarding patients’ condition. Appropriate training of team members in the technique of conscious sedation , by following hospital standard protocols.
The unit must develop and create a work environment that the staff motivated to work together and also help each other constantly to prevent from occurring of any errors, and if any errors happen they freely report the incident detailed early enough to configure a solution to solve the problem as a team.
There must be an implemented of the safe medication administration by a double checking of the high risk medication to prevent any over dose administration of medications to the patient. It should be standard policy enforcement regulation in the matter of the proper stocking of the rooms with the functional equipment such as: oxygen, suction, gloves, masks, etc by the staff to ensure the safe and prepared environment in the case of emergency in the Emergency Department. It would be necessary to constantly evaluate the system to ensure that there are no kinks, and if there is any so the necessary changes can be made. Implementation of the intervention will generate a system which is more unified and it is based upon the effective and proper training and communication among the staff to practice in their duty in order to maintain the highest safety in care of the …show more content…
patients.
C2. Pre-Steps
In order to place the successful implementation of the new system, first it must be analyzed.
In the FMEA pre-steps the team must be identified and the team members should list the failures which can occur in the system. The team must anticipate the effect and recognize by prioritizing the interventions in the areas with the greatest concern those with the one of the most significant effect. After prioritizing the failures in the system, the team must address the failures which have the greatest concern. Prior to the quality effort improvement, the data is evaluated regarding the medication administration during the conscious sedation procedure in order to be able to compare the before and after result. The evaluated data should include both positive and negative sides of the process and also the outcome of the process before and after the quality effort improvement process.
C3. Three Steps
FMEA is a process that has three steps “Each failure mode has a potential effect and each potential effect has a relative risk associated with it. The relative risk of failure and its effects is determined by three factors: severity, occurrence, and detection” (ICMA, 2014). Each factor in three steps of FMEA is rated on a scale of one to ten numbers, with the number ten being the most significant. Severity is a factor which is the consequences of the each failure mode that happens. For instance, never events, and patient harm, that would result from each failure mode if it did in fact take
place. In the case of Mr. B the severity was the event of patient death, which was considered the final outcome in the scenario after the result of the system failure. The second factor in the three steps of FMEA is the Occurrence which refers to the assessing the likelihood of the risk involved and the likelihood of the process that the failure can happen. In the Mr.B case by referring to the occurrence factor and knowing that the conscious sedation medication administration errors could have happened, it could have helped the staff to double check the medication before administration and also it could have helped them to have the proper training before the conscious sedation medication administration, to prevent any life threatening event, and minimizing the risk.
The third factor of the three steps FMEA is the detection, meaning if the failure occurs will we know it? Detection factor refers to the reorganization of the cause and the failure mode before it cause harm to the patient. In the Mr.B case the detection factor would have benefited the patient by recognition of the system failure prior of his status changes from bad to worst.
D. Nurses Roles:
Nurse J could have prevented the incident from happening, if she could have pursued the proper protocol in regards to conscious sedation, by close monitoring and reassign the patient status and the respiration and also the cardiac ECG. Also she could have stopped the incident by the proper communication among the supervisor in charge and the physician on the unit.
References
Sorbello, B. (2008, October 11). Responding to a sentinel event - American Nurse Today. Retrieved February 15, 2015, from http://www.americannursetoday.com/responding-to-a-sentinel-event/
Institute of Healthcare Improvement (2015, January 1). Retrieved February 15, 2015, from http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx