1. Root Cause Analysis

Root cause analysis(RCA) is an inquiry process through which healthcare practitioners examine an adverse health outcome to understand how it occurred, and the significant factors contributed to its occurrence. Contrary to other investigations, RCA identifies the causes of such events with the aim of applying the results in the development of preventive measures. Health care centers do not use the results of the analysis to place blame on the causing events or people but make adjustments within the facility that can avoid such incidents in the future. RCA uses such events as case studies to help in improving patient care and safety.

A1. RCA Steps

RCA follows a systematic approach to make follow up of all steps leading to the sentinel event. The Institute​ of ​Health​ ​Improvement ​ (2017) identifies six stages through which health practitioners carry out an analysis of the events and develop preventive strategies. The first step involves a description of the actual event to help the team conducting the study have a clear picture. The team gets the information from the staffs who were involved or observed the whole event as well as records of patient admission (Charles et al., 2016). In the second step, the team analyzes what the obtains as a description of the entire event to identify what would have happened to avoid the negative results.

The team in step three carries out a causative analysis to identify the factors that led to the event. A fishbone structure which shows cause and effect serves as a useful tool in the step (Institute for Healthcare Improvement, 2017). In the fourth step, the team develops an account of the connection between the cause and the event. The account has three sections which include identification of the trigger, the effects and the circumstances which contributed to the event. Such statements which the team develops follows a structure like: this occurred, led to this causing the following event. Step five involves the development of recommendations which the facility can follow to avoid the occurrence of such events. The team carries out a summary of the whole process in the last step.

A2. Causative and Contributing Factors

One of the contributing factors in Mr B case is the failure of the doctor to study the patient’s medical history as well as the medication at the time of admission. Nurse J carried out an analysis of the medical history of the patient and handled it over to the physician. However, Dr T did not consider the review when carrying out further analysis of the patient. Nurse J in the study reported that the patient had a history of prostate cancer as well as impaired glucose tolerance. Also, the last medical visit recorded high cholesterol and lipids level. Mr B was on atorvastatin and oxycodone medication to aid in relieving chronic back pain.  Another information recorded during admission was the weight at 175 pounds, HR-88 (regular), B/P 120/80, R-32 and T-98.6.

Dr. T failure to follow the examination during further analysis led to the administration of excess diazepam 5 mg and hydromorphone 2 mg IVP. The information about oxycodone and weight could have helped the doctor to know that the drugs needed time to effect sedation other than offering repeated dose with intervals of 5 minutes. Administration of excess diazepam and hydromorphone leads to toxicity, low blood pressure as well as impaired respiration causing death which is one of the factors to the incidence. The doctor also failed to take consideration of the time that the drug takes to lose its effect on the body. The consideration would have perverted them from administering sedative drugs at short intervals of 5 minutes and therefore, avoid overdose.

Another factor contributing to the event was the failure of nurse J to closely monitor Mr B as the sedation drugs react with the body. Sedation policy procedure recommends that a nurse monitors ECG during sedation until the patient is awake and functioning as required. Nurse J was also neglected to offer the patient oxygen supplement throughout other than after the procedure. The effects of the drugs are low blood pressure and impaired respiration which helps the nurse note that they are not reacting in the right way. The nurse could have reversed the process to control the effect of the drug. However, J was too busy with other patients such that there was no time to take the deteriorating blood pressure and respiration serious and offer help at the right time. Nurse J could have stayed close to the patient monitoring the blood pressure, respiration, mentation, and HR. However, the facility did not have enough nurses for close monitoring meaning that the fault was insufficient staffing.

Also, there was negligence from LNP to report the changes in blood pressure at and reduced oxygen saturation at 85% to either Dr T or nurse J. instead of following safety measures and communicating, LNP sets the alarm again and restarts reading of the blood pressure. The person who gives communication to nurse J about Mr B’s deteriorating blood BP and oxygen saturation is the son after the alarm sounds. At this time, the condition is worse at 58/30 blood pressure and 79% oxygen saturation. Another mistake arises where the nurse instead of starting CPR decided to call the Start code. Starting of CPR immediately could have raised the rate of the patient to survive. Although the BP normalizes at 110/70 after the Start code intervention, Mr B functions on a ventilator a condition which could have been prevented with an immediate CPR. The factors which led to the event, therefore, include understaffing, lack of following proper procedure and poor priority on patient safety. Could the facility, nurse LPN and the doctor have observed the factors, Mr B would not have died.

1. Improvement Plan

The report from cause and effect does not end at the RCN but offers a lead to developing a plan to prevent the occurrence of such events. The plan requires a team that comprises of different members of the health care both the practitioners and the management (Institute for Healthcare Improvement, 2017). A multidisciplinary team is essential because the factors of the event are diverse touching several departments. The team can comprise of the doctors, clinical nurse officer, LPN, RN, as well as the director. The team reviews the cause-effect analysis to recommend changes and improvements which the various departments and individual persons should make to avoid such an event.

One of the recommendations from the analysis is regular training and development programs for the nurses as well as workshops combined with simulated presentations. Such programs will help to address issues in administering sedation among other therapies. The workshops will help the practitioners exchange ideas on what worked best for others to come up with an improved strategy of carrying out the same sedation. The education should also include exposure to policy and procedures in different care. In Mr B’s case, there would have been a constant supply of oxygen throughout the sedation if the nurse was conversant with the procedure. Another education competency is communication in all medical staff. There should be regular meetings and forums where teams report any challenges like staffing which may prevent them from offering the right care.

The facility should also have a procedure of every therapy and care at a strategic point in the observation and wardrooms. It will help the doctors and nurses stick to every step to avoid cases where they miss an important part as the case of Mr B where they omitted the ECG monitor. The Doctors should also adhere to the analysis of the medical reconciliation and admission procedure which the nurses present to them. The management should also carry out regular check up on needs such as staffing and equipment to support the staff in their practices.

B1. Change Theory

Change theory is an approach which guides on the process of effecting change. According to Lewin’s, the plan has three stages. The first stage of bringing in change is unfreezing where the team brings attention to the problems and therefore need for change to the entire community (Hussain et al., 2018). The next step is moving where the team develops a change plan, goals and policies and implements it offering support to the affected people (Hussain et al., 2018). The last step is freezing where the team ensures that every part is participating in the change by providing support and creating strict procedure and policies.

In the case of Mr B, the unfreezing stage is informing all staff in the facility they need to change through the exposition of all the problems which led to the event. The team carries out an RCA and makes the people aware of the findings while showing the need to change. In the moving stage, the team implements the recommendations which it identified as the best practice to avoid such events and offers support as recognized as increase staffing. In the last freezing stage, the team offers support and sets policies to ensure that the change maintains.

1. General Purpose of FMEA

The Failure​ ​Modes​ ​and​ ​Effects​ ​Analysis​ ​(FMEA)​ is a strategy to identify the chances of any part of the plan prone to fail in meeting the goal of preventing the occurrence of the analyzed incidence (Institute for Healthcare Improvement, 2017). The analysis outcomes help to make changes in the plan to ensure that it does not fail in its goals.

C1. Steps of FMEA Process

The first step in the process is the selection of a plan that requires FMEA for example communication between staff. The identified process should be short for useful analysis. In the second step, a team is selected which comprises of representatives from different departments which the process effects (Institute for Healthcare Improvement, 2017). The third step involves outlining the processes to consider and the steps to follow. The team identifies the cause of process failure in the fourth step. The fifth step requires allocation of a risk priority number RPN including the likelihood of occurrence, detection, and severity. In step six, the team multiplies the three numbers to get the actual RPN for each process to get the probability of each failure occurring (Charles et al., 2016). The failure mode with the highest number which cannot exceed 1000 is more likely to happen compared to the mode with the smallest value which cannot be less that one. The team selects the first few modes which are more likely to occur depending on PRN to start working on them. Lastly, the team develops strategies to improve the plans.

C2. FMEA Table

1. Intervention Testing

Intervention testing is the examination of the plans to find out whether they are working or there are adjustments needed to make them effective. The team will carry out an analysis of outcomes after sedation to find out whether the training programs impacts competencies (Institute for Healthcare Improvement, 2017). Where there are more recoveries from sedation, the training is running well, and where the recoveries are less with more deaths, an improvement is needed. There will be a frequent two-week nurse, equipment and facility- patient ratio evaluation to find out whether managers are improving numbers of staff, equipment, and facilities size. The team will check after every two weeks whether there are procedures for sedation administration in wards, theaters, and emergency rooms. The team will also evaluate whether there are facility meetings every month. Where the results are negative, the plan will go through improvement or recommendation of a better one.

1. Demonstrate Leadership

Demonstrating leadership as nurses are the foundation of offering effective care and ensuring a positive outcome of patients. Nurses can show leadership by providing evidence-based practice. It involves the implementation of the learned skills during development programs. Another way through which nurses can demonstrate leadership is through quality care administration of patients. Quality care in a facility is possible when nurses follow the identified improvement plans by the RCA team. Following the recommendations ensures that patients receive appropriate drug administration and care. Nurses should also participate in RCA teams to share ideas on the best strategies to improve care. Involvement shows that the nurse is responsible for patients.

E1. Involving Professional Nurse in RCA and FMEA Processes

Involvement of the professional nurse in both RCA and FMEA demonstrates leadership qualities through assignments to carry out analysis of factors that affect patient care and positive outcomes. Allocating nurses in such roles where they can deliver in coming out with best plans and practices shows that they are willing and competent to manage patients in the right way. Also when nurses can deliver in RCA and FMEA teams, it shows that they are cautious with what affects the patients whom they are supposed to protect. The nurses show that they are aware of the structures and processes in healthcare practices as well as able to lead a team towards best outcomes. All the skills which they demonstrate when they successfully deliver in the teams are what a leader should have and therefore shows leadership qualities.

References

Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., … & Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient safety in surgery, 10(1), 20.  https://doi.org/10.1186/s13037-016-0107-8

Hussain, S. T., Lei, S., Akram, T., Haider, M. J., Hussain, S. H., & Ali, M. (2018). Kurt Lewin’s change model: A critical review of the role of leadership and employee involvement in organizational change. Journal of Innovation & Knowledge, 3(3), 123-127.

Institute for Healthcare Improvement. (2017). Failure Modes and Effects Analysis (FMEA). Retrieved from http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx