RTT2 Organizational Systems
RTT Task Two: Case Study
Western Governors University
Sentinel Event Case Study
Human interaction between individuals and systems does not occur in a vacuum, rather it occurs in a dynamic and multidimensional setting. From a structural and procedural system performance perspective, the nursing care environment “is perfectly designed to get the results it gets” (LLoyd, Murray, & Provost, 2015). When mistakes happen in healthcare, all Joint Commission accredited healthcare organizations are obligated to analyze the care environment to assess for opportunities to improve the structural and procedural elements that lead to care failures, as in the fictitious sentinel event case of Mr. B who presented to the emergency department for a manual reduction under moderate sedation of a dislocated left hip after sustaining a ground level fall. This review focuses on root causes of the sentinel event including errors and hazards present in the care environment, provides recommendations for an improvement plan to reduce the likelihood of a recurrence of this event in the future, evaluates the likelihood of success in reducing recurrence after the recommendations are implemented, and discusses the key roles nurses at all levels play in improving and achieving sustained quality patient care and outcomes.
A. Root Cause Analysis
When a patient with a relatively benign medical history, such as Mr. B, presents to an acute care setting for treatment of a dislocated hip and subsequently dies within a week there is cause for concern and a need for a root cause analysis. A root cause analysis (RCA) is the direct application of quality improvement principles and methods focused on uncovering system and process deficiencies that lead to care failures (Werner, 2011). An RCA begins by systematically answering the following four questions (Huber & Ogrinc, 2015): What happened? Why? How will we prevent it in the future? Will our changes actually cause improvement?
To begin answering
Western Governors University
Sentinel Event Case Study
Human interaction between individuals and systems does not occur in a vacuum, rather it occurs in a dynamic and multidimensional setting. From a structural and procedural system performance perspective, the nursing care environment “is perfectly designed to get the results it gets” (LLoyd, Murray, & Provost, 2015). When mistakes happen in healthcare, all Joint Commission accredited healthcare organizations are obligated to analyze the care environment to assess for opportunities to improve the structural and procedural elements that lead to care failures, as in the fictitious sentinel event case of Mr. B who presented to the emergency department for a manual reduction under moderate sedation of a dislocated left hip after sustaining a ground level fall. This review focuses on root causes of the sentinel event including errors and hazards present in the care environment, provides recommendations for an improvement plan to reduce the likelihood of a recurrence of this event in the future, evaluates the likelihood of success in reducing recurrence after the recommendations are implemented, and discusses the key roles nurses at all levels play in improving and achieving sustained quality patient care and outcomes.
A. Root Cause Analysis
When a patient with a relatively benign medical history, such as Mr. B, presents to an acute care setting for treatment of a dislocated hip and subsequently dies within a week there is cause for concern and a need for a root cause analysis. A root cause analysis (RCA) is the direct application of quality improvement principles and methods focused on uncovering system and process deficiencies that lead to care failures (Werner, 2011). An RCA begins by systematically answering the following four questions (Huber & Ogrinc, 2015): What happened? Why? How will we prevent it in the future? Will our changes actually cause improvement?
To begin answering
References: Cherry, B. (2011). Nursing leadership and management. In B. Cherry, & S. Jacob, Contemporary nursing: Issues, trends, and management (pp. 333-363). St. Louis: Mosby. Draper, D., Felland, L., Liebhaber, A., & Melichar, L. (2008, March). The role of nurses in hospital quality improvement. Retrieved from Robert Wood Johnson Foundation: http://www.rwjf.org/en/research-publications/find-rwjf-research/2008/03/the-role-of-nurses-in-hospital-quality-improvement.html Egan, T. (2007). Moderate sedation administration for nonanesthesiologists: Scientific basis of safe clinical practices. Retrieved from Medscape Nurses: http://www.medscape.org/viewarticle/567803 Huber, S., & Ogrinc, G. (2015). How a root cause analaysis works. (K. Vega, Ed.) Retrieved from Institute for Healthcare Improvement: http://www.ihi.org/education/IHIOpenSchool/courses/Pages/default.aspx Institute for Healthcare Improvement. (2015). Failure modes and effects analysis tool. Retrieved from Institute for Healthcare Improvement: http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx Lenburg, C. (2011). The influence of contemporary trends and issues on nursing education. In B. Cherry, & S. Jacob, Contemporary nursing: Issues, trends and management (5th ed., pp. 41-70). St. Louis: Mosby. LLoyd, R., Murray, S., & Provost, L. (2015). Fundamentals of improvement. (D. Ranganathan, & J. Roessner, Eds.) Retrieved from Institute for Healthcare Improvement: http://www.ihi.org/education/IHIOpenSchool/courses/Pages/default.aspx Sherwood, G., & Hicks, R. (2011). Quality and safety education in nursing. In B. Cherry, & S. Jacob, Contemporary nursing: Issues, trends and management (5th ed., pp. 464-475). St. Louis: Mosby. Werner, K. (2011). Quality improvement and patient safety. In B. Cherry, & S. Jacobs, Contemporary nursing: Issues, trends, and management (5th ed., pp. 442-463). St. Louis: Mosby.