Wgu Nursing Analysis Paper

Running Head: ANALYSIS OF CIRCUMSTANCES IN A PATIENT DEATH

Analysis of Circumstances in a Patient Death
(my name)
Western Governors University

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Analysis of Circumstances in a Patient Death
Healthcare offers a myriad of opportunities. There are many opportunities in which healthcare professionals are able to help patients, and there are many opportunities for failure with patients. When an unexpected outcome occurs, it is prudent to explore the occurrence and the path which resulted in this outcome. This paper describes the use of Root Cause Analysis
(RCA) in a scenario involving a patient death, and then utilizes Change Theory and Failure
Mode and Effects Analysis (FMEA) to demonstrate effective
ways to prevent recurrence.
A. Root Cause Analysis
Root Cause Analysis (RCA) is a process which can be used to help identify causes of sentinel events. A Sentinel Event is “an unexpected occurrence involving a patient death or serious physical or psychological injury or the risk thereof” (Cherry, 442). The intent in conducting a Root Cause Analysis is to determine causative factors so that similar events can be prevented in the future. The Root Cause Analysis process should not be used if the event is the result of purposeful ill intent, neglect, or a criminal act. This process is not used to blame an individual for the error, but rather to identify causes so that the event will not happen again
(Huber & Ogrinc, 2014). The scenario which is being examined involves the death of a Mr. B,
67-year-old male who presented to the local Emergency Department with a displaced left hip.
In order to conduct the Root Cause Analysis, an interdisciplinary team must be selected to examine the event. The ideal size for this team would be four to six members. It would be appropriate to include someone from Risk Management and the Quality Improvement
Departments. In order to provide the most insight into this event, it would be appropriate to include Nurse J and Dr. T. Since Nurse J and Dr. T are intimately involved in this event, there is

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the possibility that they could feel that the examination of this event is being conducted in order to place blame. It is important that all members of the team as well as administrators understand that this is not the case. The team will not be effective if they do not clearly understand the purpose of this activity (Huber & Ogrinc, 2014). Within the team, there are four roles which should be filled: team leader, advisor, recorder, and team member. Leadership and
Administration should be involved in any Root Cause Analysis in a supportive role. If they do not provide the support and resources for the team they will not be successful. Team members must be allowed the time and resources to complete the Root Cause Analysis, Failure Modes and
Effects Analysis, and implementation of changes to prevent recurrence.
After the team has been compiled, a meeting must be scheduled in which they begin the process of gathering information. Medical records, incident reports, personal interviews or accounts of the event are useful in determining the timeline that lead to the death of Mr. B.
Information should be gathered from all available resources. A flowchart may be useful at this point to help understand what happened leading to the event, when these precursors happened, and how they played into the sentinel event.
After the team determines exactly what happened, they should focus on what should have happened. It is important to review institutional policies and procedures, available best practices models, and medical literature. By comparing what actually happened with what should have happened, the team will be able to identify the differences in the two scenarios.
A Root Cause Analysis is helpful in identifying causes and contributing factors. One easy way to narrow the focus to identify causes is to ask “Why?” five times (Williams, 2001). In this scenario the first thing that could be asked is “Why did Mr. B. die?” The answer might be

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“Because he experienced respiratory suppression.” The next question could ask, “Why did Mr.
B have respiratory suppression?” The answer might be “Because he was medicated and inadequately monitored.” The next question might be, “Why was Mr. B inadequately monitored?” The answer might be “Because staffing in the ED was not adequate for the patient load.” The next question might be, “Why was staffing not adequate?” The answer might be,
“Because the Emergency Department staff did not use resources available. The staff could have called for extra help.” In the scenario being examined in this paper, one of the causative factors of Mr. B’s death was his cessation of breathing. Some of the contributing factors include inadequate monitoring, poor staffing for patient acuity, and disregard for conscious sedation policy. After the cause is identified, specific causal statements must be written. Each causal statement should include three parts: the cause, the effect, and the event. This statement should interlink all three of these components (Huber & Ogrinc, 2014).
Another important aspect of Root Cause Analysis is examining what can be done to prevent the event from happening again. Brainstorming preventative actions can be one of the tasks of the team. The team needs to be prepared to discuss how they will be able to demonstrate that the changes they suggest implementing will improve system safety.
A1. Errors and Hazards
A hazard is something that could possibly be a threat. One of the hazards in our scenario was the possibility of over medication of Mr. B. This threat became an error when it actually occurred. An error is an actual mistake that is made. Over medication was an unintended mistake. It occurred because of a bad judgment.

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B.
Improvement Plan
Change is difficult for most people. Often more time is expended in resisting change than it would take to actually make the change. Change Theory, developed by psychologist Kurt
Lewin, acknowledges the difficulty in making change. Lewin theorized that there are three distinct stages in organizational change: unfreezing, changing, and the freezing (Williams, 2014).
Lewin believed that in order to successfully implement a change in an organizational system, the people in the organization must go through all three of these stages. To “unfreeze” a behavior, the behavior must be first identified. In the given scenario for this paper, one of the behaviors that should be changed is the lack of regard for the Conscious Sedation policy. In order to
“unfreeze” this behavior, staff must first accept that this is a behavior that has been used and understand the need for a change in that behavior. It would be beneficial to discuss with staff their reasons for disregard of the policy. Once the staff accepts the fact that a change needs to be made, the next stage of “change” may be embarked. In the “change” stage staff would identify the desired behavior and implement it. In this scenario, staff would acknowledge that
they disregarded the Conscious Sedation policy and a change in process would be discussed and implemented. At this point, a new process or policy could be considered or the old one could be implemented with a little change. In the next instance of Conscious Sedation, the agreed upon change should be made. The final stage is “freeze”. After repeating the change on several occasions, the new behavior should be engrained and become the standard behavior. Mock situations should be considered so as not to place any patients at risk and to reinforce the appropriate new behavior. After much practice, the newly engrained (“frozen”) behavior will become natural to staff thereby reducing the likelihood of a recurrent error.

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The effectiveness of the change must be measured. One useful method is PDSA. This method uses four steps: Plan the change, “do” the change, study the change, and “act” on the findings of this assessment of change (Lloyd, Murray, & Provost, 2014). When planning the change, objective measures should be set in place and plans for collection of required data must be made. In the “do” step, the plan must be implemented and the findings documented. After these first two steps, the necessary step of “studying” the collected data occurs. This step should include a comparison between what the expected and actual outcomes. Finally the “act” step should be undertaken. This last step is dependent on thoroughly completing the first three steps.
After repeatedly practicing the new Conscious Sedation procedure and analyzing the results of making the change, determination as to whether or not this is an effective change can be made.
C. FMEA (Failure Mode and Effects Analysis)
A Failure Mode and Effects Analysis (FMEA) is “a systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change”
(IHI, 2004).
C1. Interventions
It is important to choose appropriate interventions when interested in making an impactful change. As noted in the Improvement Plan section of this paper, changes are sometimes better tested in a simulation laboratory environment. This removes the patient risk probability from the equation. After several “tests” in the simulation environment, the intervention results should be evaluated. If the results are positive, the intervention should be taken out to one unit and implemented. After implementing this intervention on this small level

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another evaluation should be done. Once the intervention has been satisfactorily tested in small controlled environments, the intervention may be moved out to other units until it becomes accepted practice.
C2. Pre-Steps
Preparation for a Failure Mode and Effects Analysis includes three major steps: identifying the process to be examined, forming a multidisciplinary team, and actually scheduling and conducting a meeting to detail the actual steps in the process being examined
(IHI, 2004).
Step one is identifying the process. This is important in assuring that the results of your
FMEA be useful. If you do not identify the correct process in the beginning, the team could waste a great deal of time and effort in a project that may not be applicable to the desired endpoint. Step two is identifying the multidisciplinary team that will conduct the FMEA.
Representatives for each role that may play a part in the process being examined should be involved in the team, regardless of the perception that any given role be minimal in the process.
Someone with a small role in the process may have key information that may hugely impact the analysis. In our scenario for this paper, the following individuals would be used on this interdisciplinary team: An Emergency Department RN, An Emergency Department MD, A
Nursing Administrative Supervisor or someone from the inpatient sector of the hospital who would have decision-making capabilities regarding reassigning staff based on need, a Critical
Care RN, A Risk Manager, a representative from the Quality Improvement Department, an
Emergency Department LPN, and a Respiratory Therapist.

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Step three is examination of the steps in the process. This should occur at the first team meeting. A detailed evaluation should be conducted by the team in an attempt to include even the smallest steps in the process being examined. The steps may be listed or diagramed. It is often easier to visualize if a diagram is done.
C3. Three Steps
FMEA contains three steps: the severity of the occurrence, the likelihood of the occurrence happening again, and the likelihood of detection of the occurrence. Each of these must be considered. The three items are scored on a scale of one to ten. By multiplying the three scores together, a Risk Priority Number (RPN) is assigned. It is better to have a low Risk
Priority Number.
Assessing the severity may be the easiest of the three steps. Death would be the most severe outcome. Minimal injury, minimal costs, minimal loss of time, and/or minimal opportunity loss would be examples of less severe outcomes. Death would receive a Risk
Priority Number of 10. An occurrence that would receive a score of one would not be likely to result in harm.
Detecting the likelihood of recurrence of the event would be best done in an interdisciplinary team, considering all possible outcomes. Input from all team members could identify scenarios that would not have been considered without a team approach. An occurrence that is likely to recur would receive a score of ten. An occurrence that is highly unlikely to occur would receive a score of one.

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The likelihood of detecting the occurrence if it happened again is the last of the three steps. An occurrence that is not likely to be detected if it recurred would receive a score of ten.
An occurrence that is likely to be detected if it were to recur would receive a score of one.
The Risk Priority Number is helpful when there are several FMEAs being evaluated. The
Failure Mode with the highest number would be the best mode to target for changes.
D. Key Role of Nurses
The role of the Professional Nurse in improving patient care is multifaceted. Regarding
RCA or FMEA, the nurse should feel compelled to participate in the teams in order to improve the care of patients and in order to prevent another sentinel event (for example, prevent another patient death from occurring like Mr. B’s). According to the American Nurses Association Code of Ethics, the Professional Nurse is committed to the patient, always acting to protect the patient.
The Professional Nurse is accountable for her actions and for any actions which are delegated.
The nurse collaborates with others to protect the patient and to improve the quality of patient care (ANA, 2001). In our scenario, Nurse J would actively participate in the RCA and FMEA multidisciplinary teams to help assure the best quality of care for her patients.

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References
American Nurses Association, (2001). Code of Ethics for Nurses with Interpretative Statements.
Retrieved from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNur ses/Code-of-Ethics.pdf .
Cherry, B. & Jacob, S. (2011) Contemporary Nursing: Issues, Trends, and Management (5th Ed.)
St Louis, Missouri: Elsevier Mosby.
Huber, S. & Ogrinc, G. (2014). Institute for Healthcare Improvement. PS 104 Lesson 2: How a
Root Cause Analysis Works. Retrieved from http://app.ihi.org.
Institute for Healthcare Improvement, (2004). Failure Mode and Effects Analysis (FMEA) Tool.
Retrieved from http://www.ihi.org/knowledge/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx. Lloyd, R., Murray, S., & Provost, L. (2014). Institute for Healthcare Improvement. QI 103
Lesson 1:Measurement Fundamentals. Retrieved from http://app.ihi.org.
Williams, D. (2014). Institute for Healthcare Improvement. QI 105 Lesson 1:Overcoming
Resistance to Change. Retrieved from http://app.ihi.org.
Williams, P. M. (2001). Techniques for Root Cause Analysis. Baylor University Medical Center
Proceedings, 14, 154-157.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1292997/?report=classic.