Organizational Systems and Quality Leadership Task 2 Western Governors University July 12, 2020
Organizational Systems and Quality Leadership Task 2 Root Cause Analysis Root cause analysis (RCA) is a systematic methodology utilized to study critical detrimental incidences within the health care system. A primary perception of RCA is to distinguish fundamental dilemmas that enhance the possibility of inaccuracies instead of fixating on oversights made by a person (Patient Safety Network, 2019). An integrative panel of individuals uses the RCA method to determine what transpired, why the events took place, and how to avoid the incident from reoccurring. The group concentrates on the “how” and “why” and not “who” (U.S. Department of Veterans Affairs, n.d.). By analyzing how and why the event occurred will aid in preventing critical incidences in the future. RCA Steps Step One: Identify what happened The group of individuals designated to investigate the incident determines what occurred in a thorough and factual style. To understand the information more distinctly, the group of individuals may create flow charts or pictorials to visualize the incident. Step Two: Determine what should have happened The group needs to establish what perhaps may have resulted in optimal circumstances. It is beneficial to create a flow chart and with these findings and evaluate them alongside step one. Step Three: Determine the causes During this phase, the project group explores circumstances that precipitated the occurrence. They analyze the most plausible and relevant details at this time. Several professionals propose that RCA groups inquire to the why of the situation five times to arrive at an explanation. A
Distributing the synopsis is the occasion to connect with essential individuals to precipitate the next phase in corrections. Flow charts are useful at this stage to aid with clarifying information (Huber & Ogrinc, 2014). Causative and Contributing Factors The first error to occur within the scenario is not following protocol for conscious sedation. The nurse did not place Mr. B on continuous blood pressure monitoring, ECG, or pulse oximetry reading during the procedure and per policy. Possibly insufficient knowledge regarding medication onset, peak, and duration contributed to Mr. B experiencing respiratory distress and hypotension. According to the scenario, Mr. B was breathing 32 breaths per minute upon arrival in triage at the emergency department. Rapid breathing or tachypnea is an indication that oxygen levels are low and supplemental oxygen is beneficial (Healthline, 2017). As for the medication, intravenous diazepam acts within one to three minutes of administration and has lasting effects of greater than twelve hours (Dhaliwal, Rosani, & Saadabadi, 2020). Hydromorphone is a powerful pain reliever with a swift reaction time within five minutes of administration, short peak effect time of ten to twenty minutes, and a short half-life of three to four hours (Colin, & Ahtsham, 2006). Upon triage admission, Mr. B was tachypneic with his respiratory status at 32 breaths per minute, with no oxygen saturation level taken. Along with oxygen therapy, continuous blood pressure readings, and ECG monitoring for Mr. B should have been in place, and a nurse in the room with him as well. Still, according to the scenario, hospital policy was not followed, and he did not receive any of those above until it was too late. With the use of continuous blood pressure monitoring, oxygen sensors, and cardiac monitoring as an aid in identifying alterations in heart rate, oxygen levels, and heart rhythms, this sentinel event might not occur.
A second error is the LPN not reporting the low oxygen level of 85% to the RN and not placing Mr. B on supplemental oxygen at the time of this finding. The scenario states that respiratory is available as needed. With the RN being extremely busy, the LPN can consult respiratory therapy for instructions. This error is possibly due to a lack of training or improper staffing, leading to hurried conditions. As per the scenario, the emergency department was becoming understaffed with only one RN and one LPN. The RN has two other patients, the ED is receiving an emergency transport patient, and the lobby has a barrage of new patients waiting. The failure to request additional staff to assist with patient overload also was a factor giving rise to Mr. B’s adverse events. Improvement Plan Preliminary steps in initiating improvement methods are to establish a team. The team should consist of the emergency room director, a representative from risk management, nurse manager of the emergency department, the director of nursing, a manager from respiratory therapy, and an ancillary staff member. The next step is to determine what took place as accurately and thoroughly as possible. The “what” will come from staff interviews, chart documentation review, and incident reports, and the team will construct a flow chart outlining the events in order of occurrence from the information accumulated. Subsequently, the group details what ought to have transpired. The team will craft a flow chart from this information and differentiate it from the flow chart previously constructed. Now the team proceeds to the “five why” phase to build and explore the fishbone diagram. Here the members of the team ponder the dynamics conducive to the misfortune. Next, the team members contrive causal statements involving each cause detected. The cause, the result of the cause, and how each relates to the adversity are the three components that make up the causal statements. The causal explanations
improvement team members will evaluate and follow up to ascertain compliance with the new reforms. General Purpose of FMEA Failure Modes and Effects Analysis (FMEA) is a method capitalized on to identify potential failures that may materialize. Healthcare systems use this methodology to enhance the quality of care and minimize damaging inaccuracies (Failure modes and effects analysis tools, n.d.). Teams review, evaluate, and record information using the following from the FMEA tool: Steps in the process Failure modes, or what could go wrong? Failure causes, or why would failure occur? Failure effects, or what would be the consequence of each failure? Steps of FMEA Process: To begin the process, determine a subject to evaluate. The second task to accomplish is to gather a collaborative team to oversee the activity. Thirdly, the team will formulate a reciprocally sanctioned checklist of all phases of the process requiring analysis. The fourth step spotlights the circumstance, reasons, repercussions, probability, intensity, uncertainty, and efforts of the failure. The fifth step encompasses the team appointing risk priority numbers to failure modes depicting the potential for failure, the tentativeness of failing, or the severity of the mishap. Next, the team will consider the future influence the revisions will make. The last step for the group is to observe and survey growth using RPN and specify objectives.
List 4 steps in your Improvement Plan Process *
List 1 Failure Mode per step
Likelihood of Occurrence (1–10)
Likelihood of Detection (1–10)
Risk Priority Number (RPN) Example: On-call staff must clock in within 30 minutes of being notified.
On-call staff forget to clock in when arriving to the unit.
4 5 2 40
1.Inspect medications and dosages before administration
Did not consult pharmacy for dosing instruction
4 5 5 100
2.Failure to use continuous vitals monitoring with sedation medications
Inadequate vitals monitoring. Nurse incompetence
5 5 9 225
3.Staffing numbers: Unacceptable Nurse to patient ratios
Failure to request flex/float pool nurses
7 5 4 140
4.Failure to contact respiratory therapy for assistance
Not using necessary resources Total RPN (sum of all RPN’s):
Nurses contributing to FMEA and RCA activities allow for their viewpoint regarding improving and implementing new approaches for reformations. It offers the nurse an active role to participate and be an active voice with modification measures. It is easier for nurses to communicate with other nurses instead of the “higher-ups,” and they feel comfortable in sharing feelings and insight relating to procedural change, making it easier to gather information critical to the plan. As nurses, we give thought to the entire picture instead of small elements to prevent further difficulties.
References American Nurses Association. (2015). Code of ethics for nurses with interpretive statements.
Retrieved from https://www.nursingworld.org/practice-policy/nursing- excellence/ethics/code-of-ethics-for-nurses/ Colin, J.L. McCartney, Ahtsham Niazi. (2006) Use of opioid analgesics in the perioperative period. Retrieved from https://www.sciencedirect.com/topics/medicine-and- dentistry/hydromorphone Dhaliwal, J. S., Rosani, A., Saadabadi, A. (May 18, 2020). Diazepam. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK537022/ Elsevier.Huber, S. & Ogrinc, G. (2014). Institute for quality healthcare improvement. PS 104 Lesson 2: How a root cause analysis works. Retrieved from http://app.ihi.org Healthline. (July 8, 2017). Oxygen Therapy Retrieved from https://www.healthline.com/health/oxygen-therapy Institute for Healthcare Improvement. (n.d.). Failure modes and effects analysis (FMEA) tool. Retrieved from http://www.ihi.org/resources/pages/tools/ failuremodesandeffectsanalysistool.aspx Mn Department of Health. (n.d.). Fishbone Diagram. Retrieved from https://www.health.state.mn.us/communities/practice/ resources/phqitoolbox/fishbone.html Mulder, P. (2012). Lewin’s Change Model. Retrieved from ToolsHero: https://www.toolshero.com/change-management/lewin-change-management-model/ Patient Safety Network. (September, 2019). Root cause analysis. Retrieved from https://psnet.ahrq.gov/primer/root-cause-analysis U.S. Department of Veterans Affairs. (n.d.). VA national center for patient safety: Root cause analysis. Retrieved from https://www.patientsafety.va.gov/professionals/