Root Cause Analysis
Running Head: Organizational Systems and Quality Leadership
Organizational Systems and Quality Leadership
RTT- Task 2
Tara McColeman
Student ID:000297596
Student Mentor: Kristine Warner
1
Organizational Systems
2
This report is apart of a collaborative investigation that included interdisciplinary team members: Risk Management, ED physician, Anesthesiologist, Director of Nurses, respiratory therapist, and ED Nurse Manager. The purpose of this investigation is to determine the root cause analysis (RCA) of the sentinel event, which occurred in the emergency room. Once the cause is identified, a plan of action will be established, and a failure mode and effects analysis
(FMEA) will be done to reduce the likelihood that the new processes …show more content…
implemented won 't fail.
Scenario
The patient is a 67 year elderly old male. With a history of chronic use of narcotics, takes oxycodone a very strong controlled substance, for chronic back pain he is also elderly, otherwise healthy male, lives alone and is able to perform is own ADLs.
At 1530hrs-Mr. B admitted to the ER status post tripping over his dog, brought in by a neighbor and the patient 's son. Pt. A&Ox4, unable to move his left lower extremities, the leg is swollen, painful upon touch and is shorter compared to right leg. Pt. is complaining of 10/10 pain, and tachypnea. Initial Vital Signs Pulse 88, RR 32 BP120/80. After being evaluated by the ER physician, it 's determined that the hip is dislocated.
At 1605hrs- Mr. B was given diazepam 5mg IVP, which had no effect after 5 minutes. The goal is for the patient is to reduce the hip dislocation by manual manipulation by the ER physician.
At 1615hrs-Mr. B was given 2mg of hydromorphone IVP.
At 1620hrs- Dr. T is not satisfied with Mr. B 's level of sedation and orders an additional dose of
2mg hydromorphone and 5mg diazepam IVP.
At 1625hrs-Mr.B is sedated and a successful reduction of his left hip takes place. The patient 's son is at the bedside.
Organizational Systems
3
At 1635hrs-Post-procedural VS. BP 110/62 and O2 sat 92%, pt. is on RA. At the same time, the
ER has become congested with new incoming patients, and receives an emergency rescue call enroute to the facility. The ER staff is overwhelmed with the emergency care of a patient in respiratory distress, and triaging the influx of new patients. Mr. B 's O2 sat alarms, indicating an
O2 sat of 85%; the patient is on RA, and the LVN silences the alarm, recycles the BP and leaves the room. (Without assessing the patient.)
At 1643hrs-The low O2 sat alarm keeps going off, and now the pt. 's son leaves the room, and informs the nurse that the monitor is alarming. The RN enters the room; BP 58/30 and O2 sat
79%. The patient is not breathing and no palpable pulse can be detected. A code blue is called, the RN starts CPR, and the patient is attached to the heart monitor, which shows VF. ACLS is being performed.
At 1713hrs- After 30 minutes of ACLS the ECG converts to a NSR. BP 110/70. Pt. is unresponsive, pupils are fixed and dilated, and patient is intubated and placed on a ventilator.
Sentinel Event
Seven days later Mr. B has an EEG done that confirms brain death, life support was removed, and Mr. B subsequently dies.
Root Cause Analysis (RCA) findings:
Major deviations occurred during the course of Mr. B 's emergency room visit. Failure to comply with hospital policies and procedures regarding conscious sedation, lack of knowledge regarding medication administration, and inadequate staffing ratios,
Organizational Systems
4
Error and hazards that were contributing causative factors, by the individual health care team members.
•
Mr. B wasn 't placed on a continuous B/P, ECG and pulse oximeter during the procedure.
•
Mr. B post-procedure VS. Sedated, O2 sat 92% on RA; RN didn 't provide any supplemental O2 for an O2 sat of <94%, and no record of the RR or HR.
•
The patient didn 't meet the specific discharge criteria: fully awake, VSS. Nor was he recovered properly.
•
RN-recently completed the module for conscious sedation, but didn 't question the MD 's orders regarding the protocol.
•
LPN- silences the patient 's O2 saturation alarm of 85%, and didn 't notify the RN or MD of the decrease in O2 saturation.
•
ED MD-didn 't consider the patients age, and chronic use of pain medications.
Error and hazards which were contributing causative factors, by the facility
•
The ED staff was overwhelmed, with the rapid onset of new ER admissions, additional
ER staff was not called to come in, nor was the nursing supervisor notified of the changes. •
The facility should have been placed on divergence, until the back-up staff reported to work. •
Breakdown of communication amongst the ED MD and RN, they had resources but didn 't utilize them.
Recommended Corrective Action Plan and FMEA
Organizational Systems
5
Individual Health Care members: Implementation of stricter protocols regarding conscious sedation: Effective immediately, procedural guidelines will be conducted per protocol.
Recommendations: Respiratory Therapist will be present during procedure, until patient meets discharge criteria. Within 10 days the conscious sedation protocol will be reviewed and evaluated by the committee, to ensure safe and best practices are being implemented. Within 30 days of this report, all staff including RN 's, LVN 's and MD 's will be educated on the facility 's conscious protocols. Updates and reviews of conscious sedation protocols will be reviewed by
ED staff, every 90 days, and then every 6months. Annual educational update will include: conscious sedation protocol, medication administration, and knowledge of the mechanism of action. For example in drugs there is: onset of action, peak, duration and potential side effects, and assessment of aldrete scoring, prior to discharge.
Facility Factors: Identifying protocols for safe staffing ratios: Effective immediately, the nursing supervisor will be notified of any emergency rescue transport to the facility. Within 10 days of this report, safe nursing to patient ratios will be implemented. Within 30 days policy and procedure draft will outline patient acuity levels and staff ratios. Divergence protocols implemented which assist in the determination of when to place ER on divergence. An understaffed department affects the capabilities of the emergency room to deliver safe and effective patient care.
Failure Mode and Effects analysis (FMEA): Multi-disciplinary team has been identified at the beginning of this report and will continue until the FMEA is satisfied.
Pre-Steps include:
Organizational Systems
6
Identification of the failure mode:
The primary cause of failure in this scenario is the failure of the healthcare team members to follow the conscious sedation protocol: This report will focus on education of all staff
members.
Data Collection:
The team will gather and evaluate all internal and external data, scope of practice and clinical practice guidelines as outlined by the Board of Registered Nursing. All current hospital policies and procedures as it relates to conscious sedation.
Observation and Testing of conscious sedation modules:
Conscious sedation protocols will be tested on a quarterly basis, which will include a skills test of medication administration, onset and duration of medication, assessment and evaluation using the Aldrete scoring protocol. A score of 99% pass will be required, if unable to meet this scoring guideline, then further education at the time is required.
Failure Modes and Effects analysis (FMEA)
Is a systematic three-step knowledge process based on the Department of Defense Patient
Safety Center (2004). These processes are: Severity, Occurrence and Detection.
The formula is The Risk Priority Number, or RPN, is a numeric assessment of risk assigned to a process, or steps in a process, as part of Failure Modes and Effects Analysis (FMEA). The team assigns each failure mode a numerical value from 1 to …show more content…
10.
This numerical grading quantifies a likelihood that the failure will occur, likelihood that the
Organizational Systems
7
failure will not be detected, and the amount of harm or damage the failure mode may cause to a
person.
(Institute for Healthcare Improvement 2004.)
Goals
The goal of this process is to decrease the RPN for a given high-risk process by 50 percent within 1 year.
Conclusion:
Registered Nurses have the greatest impact on patient care, they are the largest employees in the hospital, and they are usually the first person the patient interacts with and last one prior to discharge home. Nursing has changed over the past decade and has become a task-oriented profession. It would be a beneficial to each and every nurse to take professional assertive training, when orders don 't seem appropriate and voice their concerns when they feel an order is inappropriate and not be imitated or concerned if they are written up for questioning an order.
The more knowledge and further education that each and every nurse can do will empower them to provide the best care possible and maintain professional dignity.
References
Institute for Healthcare Improvement (2004.) Risk Priority Number (from failure modes and effects analysis.)
Retrieved from Institute for Healthcare Improvement:
http://www.ihi.org/resources/Pages/Measures/RiskPriorityNumberfromFailureModesand
EffectsAnalysis.aspx
Organizational Systems and Quality Leadership
RTT- Task 2
Tara McColeman
Student ID:000297596
Student Mentor: Kristine Warner
1
Organizational Systems
2
This report is apart of a collaborative investigation that included interdisciplinary team members: Risk Management, ED physician, Anesthesiologist, Director of Nurses, respiratory therapist, and ED Nurse Manager. The purpose of this investigation is to determine the root cause analysis (RCA) of the sentinel event, which occurred in the emergency room. Once the cause is identified, a plan of action will be established, and a failure mode and effects analysis
(FMEA) will be done to reduce the likelihood that the new processes …show more content…
implemented won 't fail.
Scenario
The patient is a 67 year elderly old male. With a history of chronic use of narcotics, takes oxycodone a very strong controlled substance, for chronic back pain he is also elderly, otherwise healthy male, lives alone and is able to perform is own ADLs.
At 1530hrs-Mr. B admitted to the ER status post tripping over his dog, brought in by a neighbor and the patient 's son. Pt. A&Ox4, unable to move his left lower extremities, the leg is swollen, painful upon touch and is shorter compared to right leg. Pt. is complaining of 10/10 pain, and tachypnea. Initial Vital Signs Pulse 88, RR 32 BP120/80. After being evaluated by the ER physician, it 's determined that the hip is dislocated.
At 1605hrs- Mr. B was given diazepam 5mg IVP, which had no effect after 5 minutes. The goal is for the patient is to reduce the hip dislocation by manual manipulation by the ER physician.
At 1615hrs-Mr. B was given 2mg of hydromorphone IVP.
At 1620hrs- Dr. T is not satisfied with Mr. B 's level of sedation and orders an additional dose of
2mg hydromorphone and 5mg diazepam IVP.
At 1625hrs-Mr.B is sedated and a successful reduction of his left hip takes place. The patient 's son is at the bedside.
Organizational Systems
3
At 1635hrs-Post-procedural VS. BP 110/62 and O2 sat 92%, pt. is on RA. At the same time, the
ER has become congested with new incoming patients, and receives an emergency rescue call enroute to the facility. The ER staff is overwhelmed with the emergency care of a patient in respiratory distress, and triaging the influx of new patients. Mr. B 's O2 sat alarms, indicating an
O2 sat of 85%; the patient is on RA, and the LVN silences the alarm, recycles the BP and leaves the room. (Without assessing the patient.)
At 1643hrs-The low O2 sat alarm keeps going off, and now the pt. 's son leaves the room, and informs the nurse that the monitor is alarming. The RN enters the room; BP 58/30 and O2 sat
79%. The patient is not breathing and no palpable pulse can be detected. A code blue is called, the RN starts CPR, and the patient is attached to the heart monitor, which shows VF. ACLS is being performed.
At 1713hrs- After 30 minutes of ACLS the ECG converts to a NSR. BP 110/70. Pt. is unresponsive, pupils are fixed and dilated, and patient is intubated and placed on a ventilator.
Sentinel Event
Seven days later Mr. B has an EEG done that confirms brain death, life support was removed, and Mr. B subsequently dies.
Root Cause Analysis (RCA) findings:
Major deviations occurred during the course of Mr. B 's emergency room visit. Failure to comply with hospital policies and procedures regarding conscious sedation, lack of knowledge regarding medication administration, and inadequate staffing ratios,
Organizational Systems
4
Error and hazards that were contributing causative factors, by the individual health care team members.
•
Mr. B wasn 't placed on a continuous B/P, ECG and pulse oximeter during the procedure.
•
Mr. B post-procedure VS. Sedated, O2 sat 92% on RA; RN didn 't provide any supplemental O2 for an O2 sat of <94%, and no record of the RR or HR.
•
The patient didn 't meet the specific discharge criteria: fully awake, VSS. Nor was he recovered properly.
•
RN-recently completed the module for conscious sedation, but didn 't question the MD 's orders regarding the protocol.
•
LPN- silences the patient 's O2 saturation alarm of 85%, and didn 't notify the RN or MD of the decrease in O2 saturation.
•
ED MD-didn 't consider the patients age, and chronic use of pain medications.
Error and hazards which were contributing causative factors, by the facility
•
The ED staff was overwhelmed, with the rapid onset of new ER admissions, additional
ER staff was not called to come in, nor was the nursing supervisor notified of the changes. •
The facility should have been placed on divergence, until the back-up staff reported to work. •
Breakdown of communication amongst the ED MD and RN, they had resources but didn 't utilize them.
Recommended Corrective Action Plan and FMEA
Organizational Systems
5
Individual Health Care members: Implementation of stricter protocols regarding conscious sedation: Effective immediately, procedural guidelines will be conducted per protocol.
Recommendations: Respiratory Therapist will be present during procedure, until patient meets discharge criteria. Within 10 days the conscious sedation protocol will be reviewed and evaluated by the committee, to ensure safe and best practices are being implemented. Within 30 days of this report, all staff including RN 's, LVN 's and MD 's will be educated on the facility 's conscious protocols. Updates and reviews of conscious sedation protocols will be reviewed by
ED staff, every 90 days, and then every 6months. Annual educational update will include: conscious sedation protocol, medication administration, and knowledge of the mechanism of action. For example in drugs there is: onset of action, peak, duration and potential side effects, and assessment of aldrete scoring, prior to discharge.
Facility Factors: Identifying protocols for safe staffing ratios: Effective immediately, the nursing supervisor will be notified of any emergency rescue transport to the facility. Within 10 days of this report, safe nursing to patient ratios will be implemented. Within 30 days policy and procedure draft will outline patient acuity levels and staff ratios. Divergence protocols implemented which assist in the determination of when to place ER on divergence. An understaffed department affects the capabilities of the emergency room to deliver safe and effective patient care.
Failure Mode and Effects analysis (FMEA): Multi-disciplinary team has been identified at the beginning of this report and will continue until the FMEA is satisfied.
Pre-Steps include:
Organizational Systems
6
Identification of the failure mode:
The primary cause of failure in this scenario is the failure of the healthcare team members to follow the conscious sedation protocol: This report will focus on education of all staff
members.
Data Collection:
The team will gather and evaluate all internal and external data, scope of practice and clinical practice guidelines as outlined by the Board of Registered Nursing. All current hospital policies and procedures as it relates to conscious sedation.
Observation and Testing of conscious sedation modules:
Conscious sedation protocols will be tested on a quarterly basis, which will include a skills test of medication administration, onset and duration of medication, assessment and evaluation using the Aldrete scoring protocol. A score of 99% pass will be required, if unable to meet this scoring guideline, then further education at the time is required.
Failure Modes and Effects analysis (FMEA)
Is a systematic three-step knowledge process based on the Department of Defense Patient
Safety Center (2004). These processes are: Severity, Occurrence and Detection.
The formula is The Risk Priority Number, or RPN, is a numeric assessment of risk assigned to a process, or steps in a process, as part of Failure Modes and Effects Analysis (FMEA). The team assigns each failure mode a numerical value from 1 to …show more content…
10.
This numerical grading quantifies a likelihood that the failure will occur, likelihood that the
Organizational Systems
7
failure will not be detected, and the amount of harm or damage the failure mode may cause to a
person.
(Institute for Healthcare Improvement 2004.)
Goals
The goal of this process is to decrease the RPN for a given high-risk process by 50 percent within 1 year.
Conclusion:
Registered Nurses have the greatest impact on patient care, they are the largest employees in the hospital, and they are usually the first person the patient interacts with and last one prior to discharge home. Nursing has changed over the past decade and has become a task-oriented profession. It would be a beneficial to each and every nurse to take professional assertive training, when orders don 't seem appropriate and voice their concerns when they feel an order is inappropriate and not be imitated or concerned if they are written up for questioning an order.
The more knowledge and further education that each and every nurse can do will empower them to provide the best care possible and maintain professional dignity.
References
Institute for Healthcare Improvement (2004.) Risk Priority Number (from failure modes and effects analysis.)
Retrieved from Institute for Healthcare Improvement:
http://www.ihi.org/resources/Pages/Measures/RiskPriorityNumberfromFailureModesand
EffectsAnalysis.aspx