Nursing and Patient Care

1. The general purpose of conducting a root cause analysis (RCA)

Root cause analysis refers to the procedure of finding the basic or causal factors causing a difference in performance (Joint Commission Resources, 2015).  It helps in understanding the causes of an adverse event and pointing preventable system error. A process is an effective tool that enables healthcare organizations around the globe to minimize errors and ensure that they offer quality services. The most effective RCAs focus on the whole process and the support systems involved in a particular event to decrease the overall risks linked to the process and the recurrence of the event that led to the root cause analysis (Institute for Healthcare Improvement, n.d.). The aim of the root cause analysis is to develop an action that identifies the approaches the institution plans to enact and minimize the risk of the same events coming up in the future. However, it cannot be used in cases where there is carelessness or deliberate harm.

A1. RCA Steps

Mainly, an RCA team involves four to six individuals from different professionals (Institute for Healthcare Improvement, n.d.). Also, there are six steps that are involved in the RCA process.

The first step is finding out what happened. In this case, the team of different professionals takes their time to thoroughly assess what happened (Institute for Healthcare Improvement, n.d.). They organize as well as further explain information concerning the event. Some teams take time to develop a flowchart, which is a simple tool that enables the team to have a step by step picture of what happened.

The second step is determining what should have taken place. The team needs to govern what took place in suitable conditions (Institute for Healthcare Improvement, n.d.). They can develop a flowchart using the information they have and compare it to the chart that they created in the first step.

In the third step, the team is required to determine what caused the events. In this case, they ought to ask why five times (Institute for Healthcare Improvement, n.d.). First, they focus on the direct causes and factors that contributed to the event during the process. They can use a fishbone diagram to identify factors as well as putting them in groups. There are seven diverse factors that can affect clinical practice and lead to medical error. They include the characteristics of the patient, task factors, the members of staff, teams, they working environment as well as factors related to organization and management. The last factor is the institutional setting.

Creating causal statements is the fourth step of RCA. A causal statement is important as it connects the cause that the team has identified in step three with the effects (Institute for Healthcare Improvement, n.d.). It then connects it back to the major event that leads to the RCA. The causal statement allows the team to explain how the contributory factors led to the grave results for the patient as well as the staff. It has three parts that include the cause, the effect, and the event.

The fifth step is developing a list of recommended actions to ensure that the event does not recur. They include transformations that the RCA team think will assist in ensuring that the error does not take place again (Institute for Healthcare Improvement, n.d.). There are various recommendations that the team can suggest and they mainly fall into one of the following categories. First, they can involve standardizing of the equipment. Next, the team can choose to ensure redundancy. For instance, they can use double checks or backup systems. Also, they can use forcing functions, which can prevent users physically from making the same errors. They can as well change the physical plant. They can also update or enhance the software. Other solutions can be the utilization of cognitive aids, that may include checklists, labels, or mnemonic devices (Institute for Healthcare Improvement, n.d.). The can also decide to streamline a procedure or educate the staff. Additionally, the team can suggest the development of new policies. It is important for the team to understand that some actions are more effective compared to others when dealing with the root causes of error. The actions can be divided into three, in this case, they can be strong, intermediate, or weak actions. A strong action has a high chance of minimizing or eliminating an event. An intermediate action has a high possibility of controlling the root cause. A weak action has a lower chance of working.

The sixth step is writing a summary and sharing it. In this step, the team members can engage the major players to assist in moving to the next steps in enhancement (Institute for Healthcare Improvement, n.d.). They can organize and clarify information concerning the event. Some teams decide to develop a flowchart.

A2. Causative and Contributing factors

First step: Finding what happened

In this case, we will identify what happened correctly and thoroughly (Institute for Healthcare Improvement, n.d.).

Based on the scenario, Mr. B (the patient) arrived at the emergency department at 3.30 p.m. After arriving, he is admitted to the triage room and his vital signs were taken. They include B/P which was 120/80, HR- 88 (regular), and R-32. His weight was 175 pounds. The patient had no allergies and previous falls. The numerical verbal pain scale= 10 out of 10.  His leg was shortened with swelling, ecchymosis, and limited range of motion (ROM). The patient’s leg is stabilized. He is moved to the emergency department patient room. He has a history of impaired glucose tolerance and prostate cancer. His medications include atorvastatin and oxycodone for chronic back pain. The patient is then examined by Dr. T who is the ED physician. The doctor instructs Nurse J to administer diazepan 5 mg IVP to the patient. After five minutes the doctor instructs Nurse J to administer hydromorphone 2 mg IVP. Later they administer additional 2 mg of hydromorphone IVP and an additional 5 mg of diazepam IVP. The diazepam is to help in the skeletal muscle relaxation. The hydromorphone IVP is to assist in pain control and sedation.

After sedation of the patient, a successful reduction of his hips is carried out 4:25 p.m. There is no supplemental oxygen and the procedure ends at 4.30 p.m. The patient’s B/P is 110/62 and O2 saturation is 92% at 4.35 p.m. However, his ECG and respirations are not monitored.  Later, the O2 saturation lowers to 85%. The LPN resets the alarm and repeats the B/P reading. At 4.43 p.m the patient’s B/P reading is 58/30 and the OO2 saturation is 79%. The patient is not breathing and palpable pulse cannot be detected.  A STAT CODE realizes the patient is in ventricular fibrillation. CPR is performed by the RN and the patient is intubated. He is defibrillated, hence he is administered reversal agents, IV fluids, and vasopressors. After 30 minutes the ECG is normalized and B/P is 110/70. He is put on a ventilator.

The second step is to determine what ought to have taken place (Institute for Healthcare Improvement, n.d.). In this case, in the ideal condition, the patient could have remain on continuous B/P, ECG, and pulse oximeter throughout the procedure. Mr. B was treated under moderate sedation; however, his ECG and respirations are not monitored contrary to the hospital’s policy. Therefore, Dr. T and Nurse J should have ensured that his ECG and respirations were monitored throughout the process. Also, the LPN ought to have put the patient on supplemental oxygen when the saturation alarm showed that there was low O2 saturation which was 85%.

The third step is determining the causes (Institute for Healthcare Improvement, n.d.). In this case, it is important to determine the factors that lead to the event. Some of the causes would include, lack of monitoring ECG and respiration throughout the procedure and after the procedure. Therefore, it can be said that the event was influenced by team factors. The team involved in the procedure should have made sure that ECG and respirations were monitored. The LPN nurse should have put Mr. B on supplemental oxygen.

The fourth step is developing causal statements (Institute for Healthcare Improvement, n.d.). The patient O2 saturation lowered to 85% which have led to a low flow of oxygen-rich blood to the patient’s heart thus leading to ventricular fibrillation (Chan & Ng, 2014).

The fifth step is to create a list of recommended actions to ensure that the event does not occur again (Institute for Healthcare Improvement, n.d.). First, the institution should ensure that there is redundancy. They can use double checks, to ensure that the patient is offered effective care. The double checks would make sure that the hospital policies are followed. For instance, in this case, there should be a person to check whether the patient’s ECG and respirations were monitored throughout the process.

Step six is writing a summary and sharing it with major players in the institution (Institute for Healthcare Improvement, n.d.). In this case, it was clear that Mr. B’s vital signs were taken prior to the procedure and they were normal. They included B/P which was 120/80, HR- 88 (regular), and R-32 and weight was 175 pounds. He had no history of allergies and previous falls. His leg was stabilized. He was given an overall of  10mg  diazepam IVP and 4g IVP hydromorphone. He was sedated and the procedure carried out without supplemental oxygen. His B/P was monitored; however, ECG and respirations were not monitored throughout the process. His O2 saturation during the process was 92% at 4.35 p.m. Later it lowered to 85%. The patient was not put on supplemental oxygen.  At 4.43 p.m the patient’s B/P reading is 58/30 and the OO2 saturation is 79%. It led to a low flow of oxygen-rich blood to the patient’s heart thus leading to ventricular fibrillation (Chan & Ng, 2014).  Hence, to ensure that the event does not occur again the institution should ensure that there is redundancy. They can use double checks, to ensure that the patient is offered effective care.

1. Improvement plan

First, it is important for the team to work together during every procedure. Also, there should be redundancy in the institution. In this case, there ought to be a person to make sure that all the institution policies are followed. The institution should ensure that there is a checklist in which the Doctor and the nurses should mark to make sure that all the process are followed when taking care of the patient. Next, there should be a person to check whether the institution policies were fulfilled. The improvement plan will minimize the chance of a reoccurrence of the scenario results.

B1. Change theory

In the particular case scenario, Lewin’s change theory will be used to the proposed improvement plan. The first stage of the Lewin’s change theory is unfreezing (Marquis & Huston, 2009). In this case, it is important to prepare the institution to accept the change. The medical professions will be informed about the change. The plan is to introduce redundancy inform of a checklist. They will be prepared to accept the change that is taking place. They will be informed about the failures of the current approach of working. The medical practitioners will be required to offer their opinion and in case they have any questions they can ask them.

The second step is the implementation of change. After the people have understood the need for the change, the implementation process will follow (Marquis & Huston, 2009). In the implementation process, people will be informed about the importance of having a checklist. In this case, they should be informed about what led to ventricular fibrillation in Mr. B’s case. They ought to be informed that the event could have been avoided if there was a checklist to make sure that all the hospital policies were followed especially when a patient is under moderate sedation.  Communication and time will play a huge role in the change process. In this case, everyone involved in the change process will be given time to comprehend the changes. Communication will play a huge role in ensuring that the people involved in change feel connected to the entire process.

Refreeze will be the last step in the change process (Marquis & Huston, 2009). The step will include the availability of a clear checklist that will be used by both doctors and nurses. They will work together to ensure that the entire process is successful.

1. The general purpose of FMEA

FMEA refers to a process utilized to prevent issues that are linked to product and process before they take place (Huber, 2013).  It allows an institution to identify where and how the error may occur. It also helps an organization to evaluate the impact of diverse failures so as to recognize the parts of the process that most likely need change. It allows an institution to prevent an error instead of dealing with adverse effects that are caused by a failure.

C1. Steps of the FMEA process

The first step is to select a process to assess with FMEA (Institute for Healthcare Improvement., 2004). In the particular case, the FMEA will be applied to the patient care process. It will help in preventing the event that occurred during Mr. B’s procedure.

The second step is recruiting a multidisciplinary team (Institute for Healthcare Improvement., 2004). The team that will be involved in the process include an emergency department doctor, both RN and LPN nurses. The professionals are involved in the patient care process.

The third step includes the team meeting to list every step in the procedure (Institute for Healthcare Improvement., 2004). The team will ensure that all the steps are clear and numbered. They will hold different meetings to guarantee everybody understands what is needed to be done.

Step five involves assigning a numeric value for the likelihood of occurrence, likelihood, and severity (Institute for Healthcare Improvement., 2004). The step allows the team to focus on the important areas and assist in evaluation opportunities for improvement.

The six-step is assessing the outcomes. In this case, the team will calculate the Risk Priority Number for every failure mode (Institute for Healthcare Improvement., 2004). The lowest possible score will be one and the highest 1000.

The seventh step is using the RPNs to plan enhancement efforts (Institute for Healthcare Improvement., 2004). In this case, the failure modes with the least RPNs have a low chance of affecting the entire process once they are eliminated. Therefore, they should not be considered a priority.

1. Intervention Testing

An introduction of a checklist will help in ensuring that the patients receive the best care. In this case, to test whether the procedure has worked, the institution will focus on the patients. They will assess the critical cases that have been presented in the hospital. Next, they will assess the number of deaths that occurred in the hospital due to lack of proper care. Also, the successful cases will be assessed to have a clear understanding on whether the process was effective. Also, meetings will be held, whereby, the medical practitioners will give their opinion concerning the change process. The intervention testing procedures will help in gathering first-hand information about the effectiveness of the entire process.

1. Demonstrate leadership

Nurses play an important role in patient care.

Promoting quality care

Nurses are tasked with a diverse role in promoting care. Their responsibilities include advocating for activities that help in reducing poor health outcomes (Barnard & Hannon, 2010). They are also involved in enabling as well as mediating activities to minimize poor health results. A nurse is mainly the first individual that the patient interacts with. They are tasked with evaluation patients’ needs and diagnosing illnesses. They are involved in the comprehensive standards of care and promoting health.

Improving patients’ outcome

Nurses are involved in providing compassionate care to the patient. They use compassionate care techniques to enhance patients’ outcomes (Barnard & Hannon, 2010). They also identify various factors that may affect the process of providing care to the patients. They work closely with other medical professionals to ensure that the patients are offered the best care.

Influencing quality improvement activities

Nurses are involved in influencing quality improvement activities. The offer leadership support that ensures that the activities are improved. They are well positioned to participate in the process of improving care (Izumi, 2012). They spend a lot of time with patients and understand their needs. Nurses gain information concerning the patient that help in improving the quality of activities. Therefore, the nurse should structure the work setting to ensure that other nurses can undertake effect action for enhancing care (Izumi, 2012). They can use quality circles and quality improvement forums to enable coordination of quality enhancement effort. The nurses offer the vision and gather the necessary resources to make sure that the institution’s quality improvement efforts are met.

E2. Involving a professional Nurse in RCA and FMEA processes

Nurses are involved in promoting quality care as they play the role of caregivers.  The nurse can be involved in advocating for patients as they are involved in their care and understand their needs. Nurses can offer important information concerning the patient’s needs (Barnard & Hannon, 2010). They can be involved in the critical thinking process, whereby, they offer their opinions. They should also be involved in the implementation process as they know whether the changes will be effective. By involving nurses in the two processes it helps them feel as they are part of the team. It also helps in making sure that the change process is effective.

References

Barnard, C., & Hannon, B. J. (2010). Quality improvement for nurse managers : Engage staff

and improve patient outcomes. Marblehead, MA : HCPro.

Chan, Y. K., & Ng, K. P. (2014). Physiological Basis of Acute Care. Singapore : Elsevier Health

Sciences APAC.

Huber, D. (2013). Leadership and Nursing Care Management. Elsevier Health Sciences.

Institute for Healthcare Improvement. (2004). Failure Modes and Effects Analysis (FMEA).

Retrieved October 27, 2018, from http://www.ucdenver.edu/academics/colleges/medicalschool/facultyAffairs/moc/Forms/Documents/MOCPAP/FailureModesandEffectsAnalysis_IHI.pdf.

Institute for Healthcare Improvement. (n.d.). Patient Safety 104: Root Cause and Systems

Analysis. Retrieved October 27, 2018, from http://app.ihi.org/lms/content/f99b4ea2-aeea-432d-a357-3ca88b6ae886/upload/ps 104 summaryfinal.pdf.

Izumi, S. (2012). Quality improvement in nursing: Administrative mandate or professional

responsibility? Ncbi. Retrieved October 27, 2018.

Joint Commission Resources. (2015). Root Cause Analysis in Health Care: Tools and

Techniques. Retrieved October 27, 2018, from https://www.jcrinc.com/assets/1/14/EBRCA15Sample.pdf

Marquis, B. L., & Huston, C. J. (2009). Leadership roles and management functions in

nursing. (6th ed.). Philadelphia : Wolters Kluwer.