C489 WGU Organizational Systems and Quality Leadership Task 2 FMEA Table

Root Cause Analysis

Medical errors are a serious public health problem and a significant cause of death that require attention. It is challenging to uncover a consistent cause of errors, and even when found, it is difficult to provide consistent solutions. Root cause analysis (RCA) involves the process of discovering problems, identifying causes, and coming up with more effective solutions to prevent and solve underlying issues. The primary purpose of root cause analysis is to discover the cause of a problem or an adverse event in healthcare. Secondly, RCA functions to understand how to fix, compensate, or learn from the underlying issues leading to the actual adverse outcome. Upon learning the causes and how to prevent them, conducting a root cause analysis enables providers to apply what was learned to systematically prevent future issues or to repeat successes.

RCA Steps

The Institute for Healthcare Improvement (IHI) describes six steps used to guide the root cause analysis process. Applying these steps ensures a systematic approach to understanding the cause of an adverse event and identifying system flaws that can be corrected is used (Institute for Healthcare Improvement (IHI), n.d-a). These steps include:

Step I: Identify what happened

Step II: Determine what should have happened

Step III: Determine causes

Step IV: Develop causal statements

Step V: Generate a list of actions to prevent recurrence of the event

Step VI: Share the findings

Identify what happened. As the first step of the RCA, the team must accurately identify the problem through asking questions and observation. It is important to collect information from the healthcare workers and any parties like patients who were involved (IHI, n.d.-a). During this stage, honesty and accurate identification of the errors leading to the problem are paramount.

Determine what should have happened. The second step involves going through the hospital policies and clinical practice guidelines to determine what should have happened. The use of diagrams and flowcharts can help the team identify the most appropriate ways that the problem could have been handled.

Determine causes. At this stage, the team is involved in identifying the actual causes of the adverse event observed. Direct and indirect causes are analyzed using tools like fishbone diagrams (IHI, n.d.-a). This step helps identify the patient characteristics, organizational factors, work environment, and individual provider factors that contributed to the problem.

Develop causal statements. This step involves the generation of links between what happened and how it contributed to the actual problem. These statements help to identify connections between different healthcare teams and enable providers to see how their actions led to a series of events that caused the adverse outcome.

Generate a list of actions to prevent recurrence of the event. The RCA process aims at identifying the problem and measures to prevent future occurrences. This step helps in formulating strong interventions that can be used to overcome future problems. Other stakeholders should be involved during decision-making to promote acceptance of the changes among employees and the whole institution.

Share the findings. This step involves writing a summary and sharing the findings with stakeholders. Stakeholders may include patients, nurses, doctors, administration, and other healthcare team members impacted by the adverse outcome (IHI, n.d.-a). Essential components shared include a description of the event, causes, parties involved, and ways that can be adapted to prevent future adverse events.

Causative and Contributing Factors

The observed sentinel event involves Mr. B, a 67-year-old patient brought to the emergency room (ER) after sustaining a fall. The patient’s history and physical examination indicated that he had a left hip dislocation. At this particular time, Nurse J and Doctor T are available to take care of the patient alongside many others in the ER. Based on his diagnosis, Mr.B was scheduled for a small procedure requiring manual manipulation, relocation, and alignment of the hip. The patient was sedated using diazepam and later hydromorphone in preparation for the procedure. After successful relocation of the hip, the patient developed a complication that led to delayed recovery and was later resuscitated in an effort to keep him alive. Unfortunately, the patient was later diagnosed with brain death in another healthcare facility upon referral.

Based on the events leading to the adverse outcome, the second step involves a description of what should have happened. To begin with, the patient arrived at the facility at 3:30 pm and it was until 4:05 pm that the nurse and the doctor had an opportunity to provide treatment. Because of the congested ER at this time, a backup protocol should have been initiated to allow more providers to be available to take care of Mr. B. Timely treatment with pain killers will have helped the patient relax. Secondly, the healthcare providers should have taken a complete drug history of the patient before sedation. The high doses of diazepam and hydromorphone definitely led to a respiratory depression that prompted resuscitation. Apart from these gaps, the patient was ineffectively monitored after the procedure. The nurse only left Mr. B’s son to do the monitoring and when the alarm went off, the nurse failed to put the patient on supplemental oxygen.

Mr. B’s death can be attributed to different causes, primarily over-sedation. Failure to take a complete drug history led to erroneous use of sedatives that led to respiratory distress. Secondly, the nurse failed to practice competently by regularly reassessing a patient on sedation and providing oxygen supplementation when saturation was below 85%. Lack of enough personnel in the ER is also another contributing factor to the patient’s death. Nurse J was unable to effectively monitor the patient because there was a shortage and many other patients requiring immediate attention. I might also think that ineffective collaboration between healthcare teams contributed to the problem. Despite the availability of the respiratory team, the nurse failed to seek their help when the patient’s saturation dropped to 85%.

Improvement Plan

The improvement plan to prevent future adverse outcomes will involve staff education and setting up guidelines on sedation and monitoring of patients. Staff training and education should focus on emergency patient care and moderate sedation for patients. All staff should undergo mandatory training on moderate sedation and monitoring of patients before practicing in the ER. Nurses and doctors should be educated on the importance of taking drug history and other pertinent information before sedation of patients alongside the importance of adequate monitoring of patients during recovery. The training should stress interprofessional collaboration during the care for patients in critical conditions. The nurses, doctors, respiratory teams, and other units should work together to improve patient outcomes.

The second part of the improvement plan should involve formulating clear guidelines on initiating backup protocol in the ER. The staff available during the shift should inform the charge nurse when more staff are needed. The charge nurse shall in turn inform the administration to ensure nurses and doctors on-call are informed to immediately avail themselves to the ER. Another critical part of addressing the sentinel event should involve improving staffing in the ER through administrative interventions. The employment of more nurses and doctors will improve staffing ratios in the unit leading to effective monitoring and treatment of patients.

Change Theory

Implementation of changes to address the sentinel event will utilize Kurt Lewin’s change management model. Lewin’s model consists of three phases used to guide organizational change including unfreezing, change/moving, and refreezing (Cummings et al., 2016). The first stage, unfreezing, involves creating awareness that the organization needs to make adjustments. It involves breaking down the status quo and challenging the attitudes, beliefs, and behavior of employees. The goal of this phase is to create awareness on how the current mechanisms impair the achievement of set goals.

The moving stage follows unfreezing where a transition to a new state of being is made. The stage is characterized by the implementation of new changes, educating employees, and leaving the organization to struggle with the new measures (Cummings et al., 2016). Actions during this stage include education, training, and monitoring to prevent employees from going back to the old ways. The third stage, refreezing, involves actions that can sustain the new change. Formulation of organizational policies, job descriptions, and rewarding employees can serve to sustain the new change (Cummings et al., 2016). Providing feedback and reinforcing the new changes is crucial during the refreezing stage.

The three phases of Lewin’s theory will be used to implement the new changes in the organization to address the sentinel event. During the unfreezing stage, the employees will be informed about the actions leading to the adverse patient outcome and why the new change will be essential to prevent future adverse outcomes. During the moving stage, the hospital administration and other key stakeholders will stress the importance of implementing new guidelines and improving staffing in the ER. The nurse educator will organize education and training for nurses and doctors on moderate sedation and monitoring of patients. Monitoring of staff during implementation will serve to reinforce the new changes in the facility. The refreezing stage will involve the formulation of new policies on moderate sedation, regular monitoring of similar cases in the ER, and continuing education for staff through CMEs. Rewards can be used for healthcare professionals who demonstrate improved patient care in the ER to support the new change.

General Purpose of FMEA

The failure modes and effects analysis (FMEA) is a tool used by organizations to identify failure modes within a process. The tool is used to systematically evaluate a process, determine what might fail, and what parts might require change (Institue for Healthcare Improvement (IHI), n.d.-b). The FMEA tool helps in identifying, prioritizing, and limiting failure modes within an organization.

Steps of FMEA Process

The FMEA process s conducted in five steps. The first step involves the selection of a process to evaluate. The selected process should focus on a specific area like the use of sedatives to allow the achievement of better results (IHI, n.d.-b). Upon selection of the process, step 2 involves the recruitment of a multidisciplinary team. In healthcare, nurses, doctors, administrators, and nurse educators are part of the multidisciplinary team to conduct FMEA. The third step involves listing all the steps in the process being evaluated. The use of flow charts and diagrams is crucial to identify various modes and connections with each other (IHI, n.d.-b). The fourth stage involves filling the table with the multidisciplinary team while listening to the causes of the problem. Interprofessional collaboration is crucial during this stage to accurately make connections between various modes and the potential causes of observed effects (IHI, n.d.-b). The last step involves assigning risk profile numbers (RPNs) to the failure modes to determine the likelihood of occurrence. The multidisciplinary team will evaluate the causes depending on the RPNs and make modifications to prevent adverse outcomes.

FMEA Table

See attached table

Intervention Testing

I will do intervention testing for the changes made using the plan-do-study-act (PDSA) cycle. The cycle consists of four phases that allow implementation teams to evaluate outcomes and further re-testing. During the planning phase, an education and training session will be organized for nurses and doctors in the ER. The nurse educator and the administration will also convene to formulate staffing policies in the ER including protocols for calling backup. The second phase will involve actual education of staff about moderate sedation, monitoring of patients under sedation, and interprofessional collaboration. A two-week education and training session will serve to address the problem. The study phase will involve the monitoring of nurses and doctors in the ER to ensure moderate sedation is practiced effectively. Essential components that will be monitored will include history taking, the selection of sedative agents, and monitoring of patients after procedures. The last phase will involve taking action based on the findings from the new changes. Other methods like further education and the use of strict measures will be taken to sustain the change.

Demonstrate Leadership

A professional nurse can demonstrate leadership in promoting quality care through the formulation of policies to guide employees (Boamah, 2018). The leader identifies processes that may require change and helps in determining appropriate steps to improve these areas. An example will involve the formulation of policies guiding continuing education on certain aspects of patient care to promote quality. A professional nurse can demonstrate leadership in improving patient outcomes through supporting the use of evidence-based practices in healthcare (Boamah, 2018). The nurse leader can influence the organization to support research projects and make changes based on evidence to improve patient outcomes. Lastly, a professional nurse can demonstrate leadership in influencing quality improvement activities through supporting innovation and the utilization of technology in healthcare. The nurse leader can collect views from the employees regarding areas for improvement and propose changes to the administration and professional bodies.

Involving Professional Nurse in RCA and FMEA Processes

Involving a professional nurse in RCA and FMEA processes can demonstrate the leadership qualities of change management and problem-solving. The two processes provide the leader with an opportunity to identify problems and guide the organization to make the most appropriate solutions. Problem-solving and decision-making are key qualities for nurse leaders that must be applied in RCA and FMEA processes (Boamah, 2018). Additionally, the nurse demonstrates change management by adapting to constant changes in the healthcare industry. Part of the outcomes from conducting RCA and FMEA will involve changing processes and utilizing new technologies to improve patient care. A professional nurse leader must be ready to adapt to these changes and communicate them to the employees.

References

Boamah, S. (2018). Linking nurses’ clinical leadership to patient care quality: The role of transformational leadership and workplace empowerment. Canadian Journal of Nursing Research, 50(1), 9-19. https://doi.org/10.1177/0844562117732490

Cummings, S., Bridgman, T., & Brown, K. G. (2016). Unfreezing change as three steps: Rethinking Kurt Lewin’s legacy for change management. Human Relations, 69(1), 33-60. https://doi.org/10.1177/0018726715577707

Institute for Healthcare Improvement. (n.d.-a). Patient safety 104: Root cause and systems analysis.Retrieved from http://www.ihi.org/education/ihiopenschool/Courses/Documents/SummaryDocuments/PS%20104%20SummaryFINAL.pdf

Institute for Healthcare Improvement (n.d.-b). QI essentials toolkit: Failure modes and effects analysis (FMEA). Retrieved from http://www.ihi.org/_layouts/15/ihi/login/login.aspx?ReturnURL=%2fresources%2fPages%2fTools%2fFailureModesandEffectsAnalysisTool.aspx