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C489 Organizational Systems and Quality Leadership SAT Task 2 Western Governors University Organizational Systems and Quality Leadership SAT Task 2 A. Root Cause Analysis Accidents in health care often do not stem from one single factor, often it is affected by multiple contributing factors, and to find the systemic cause of the error, one can use Root Cause Analysis (RCA). RCA systematically assesses the causes of adverse events and identifies any errors that can be corrected so it doesn't happen again. Generally there is a team of four to six people from mixed discipline set up to do this. A1. RCA Steps: There are six steps in the process of RCA
1. Identify what happened The first step is to identify where an error happened and describe it accurately. All pertinent information about the event is gathered and organized in the order it took place 2. Determine what should have happened Step two helps figure out what would have happened in an ideal situation. The team creates a flow chart to compare step 1 and step 2. 3. Determine causes After comparing the two steps, then the cause of the event is determined. What contributing factors led to the error? Per the Institute of Healthcare Improvement, experts
recommend that team ask “Why?” five times to figure out the root cause. They believe that if you ask why enough times, the closer you get to finding out the cause. Team can also use tools like fishbone diagrams to display possible causes of certain effects (IHI, n.d).
4. Develop causal statements This is where they team pieces together all the information gathered in steps 1-3 and figure out how each contributing factor led to its effects and how that overall resulted in the main event. A casual statement has 3 parts: the cause, the effect and the outcome (“How this happened...and led to something else---which causes this undesirable outcome”)(IHI, n.d.). 5. Generate a list of recommended actions to prevent the recurrence of the event The team then recommends remedies like standardized equipment, software improvements, educating staff, new policies, cognitive aids, simplifying process, ensuring redundancy, and few more that helps prevent future recurrence of the same event. Not all actions are equally effective, hence can be labeled as strong, intermediate or weak per the National Center for Patient Safety definitions. 6. Write a summary and share it Final step in this process helps summarize the process of RCA and share the findings of the process then further initiate solutions or recommended actions. A2. Causative and Contributing Factors In this scenario, the cascade of undesired events led to the unfortunate death of Mr. B. who had come to the ER for a dislocated left hip after sustaining a fall at home. Gathering information in Step 1 is very crucial to figuring out the causative and contributing factors of the event. One of the major causative factors that led to the death of Mr. B. was
understaffed. With only two nurses, a secretary and a MD, they had 4 patients to care for, one who was in need of emergent care. When all the critical events were happening the primary RN was busy with two discharges and the intake of emergent transport. The hospital had a back up staff available but they failed to ask for additional staff. LPN should have called RT in duty but that did not happen. “Why were they not staffed?” “Why did they not call for extra help that was available?” “Why was RT not called?” B. Improvement Plan First of all, I would create a team with key members like pharmacists, physicians, nursing supervisor, nursing educator, director of nursing, ER nurse, excluding those who were involved in the event. The team would then break down the event into an RCA process and identify cause and contributing factors of the event. Once that is done, they should look into the hospital policy on conscious sedation. See if there are any improvements that need to be made, any specifics that needs to be added so the staff is aware of the limits of narcotic administration. Furthermore, the team can create a pre and post procedure checklist so that the staff members are aware of signs and symptoms of respiratory depression and over sedation. Appropriate patient placement and staff to patient ratio would be next to correct. Was the patient acuity too high for the busy staff in the ER? Should the patient have been moved to ICU for more close monitoring? There should be an appropriate patient placement policy. I would also advise a safer staff to patient ratio to reduce overworking the staff and preventing mistakes.
Making sure the ER staff is aware of extra resources like the backup staff, RT, ASAP team would also help as it could have prevented the cascading decline in Mr. B’s condition. Educating the staff on how to access the resources available and knowing who can make the call to bring in backup staff all are very pertinent information that could help in time of crisis in the future. Another recommendation would be to emphasize the importance of communication between the staff. In one instance, nurse J failed to question the physician's order despite having been trained on moderate sedation. Had she questioned the order, the physician may have realized that the dose was over the implemented range in policy. The failure of the LPN to report abnormal oxygen saturation to the primary RN could have been prevented if there was open communication in the team without fear of retribution. B1. Change Theory Change in healthcare is inevitable. With growing knowledge, research and new innovations there is always bound to be change. Regardless of how valuable the change may be, it often threatens people and leaves a mixed bag of emotions. One may simply dislike change as it means having to adjust all over again. In his work Kurt Lewin identifies rules that should be followed when implementing change. He states that change should be implemented only for good reason, should always be planned, never abrupt and implemented gradually. Lastly, those affected should be involved in planning for change (Cherry & Jacob, 2019, pg 304). He also identifies three stages of change; unfreezing, moving and refreezing. The first stage of unfreezing is where the need for change is brought to the organization's attention by showing them the existing way of doing things is not working. In this scenario, the safe practice in the ER needs to be changed. It is important to show how the change minimizes harm done to patients and staff, increases patient safety and satisfaction, and overall reduces
held to go over every step of the process in detail. There may be many meetings depending on the complexity of the process and the steps. Next step calls for listing all things that could go wrong and identifying all the possible causes and consequences of each failure. After that, the team assigns a numeric value to each failure mode based on the likelihood of occurrence, likelihood of detection and the severity, which helps calculate risk priority number or RPN. RPN helps the team prioritize areas to focus and improve on. Failure mode with the highest RPN
number is prioritized first. Then lastly, using FMEA, the team creates a plan for change, evaluates the impact of change and monitor and track improvements. C2. FMEA Table: Conscious sedation protocol review Steps in the process Failure mode Likelihood of occurrence Likelihood of detection Severity RPN Creating a checklist for proper sedation prior to procedure Staff not using it 5 5 8 200 Going through post sedation checklist for proper recovery Misplacement of the checklist during transport 4 5 5 100 Highly trained RNs to work in recovery room Not having enough staff and needing to use float RNs or LPN 5 5 7 175 Appropriate dosing of narcotics based on pts weight, height and age Different level of tolerance to narcotics 4 5 8 160 D. Intervention Testing To test out the change for improvement, one can use the PDSA (plan, do, study and act). PDSA cycles allow one to conduct rapid test of change, learn from the test all while reducing the risk of bringing new change in a complex system (IHI, n.d.). One of the areas of improvement mentioned above was to go through a checklist post sedation for appropriate recovery of patients. To test this intervention, we would use the PDSA cycle. Plan: Make a post sedation checklist (that has all the key assessment, signs to look for and time slots for vitals, etc) and have staff go through the checklist every time they have post sedation patients so that they can make sure that nothing is missed during the recovery period.
change and helping people adapt to change. When we do this consistently at work, our coworkers, student nurses, preceptee can all learn from it and be influenced by it. E1. Involving Professional Nurse in RCA and FMEA Processes The RCA and FMEA process both involve the nurses and in both cases they play crucial roles. Nurses work with patients at bedside and are the last line of defense, thus their contribution in the RCA process is very important. They work with other interdisciplinary teams and actively contribute to factors that can improve patient care and provide quality care. Likewise, when bringing change to the organization that affects patient care, nurses' honest opinion matters a lot during the FMEA process. One can show leadership by being actively involved in the process of change and letting the managers or the team know what works and what does, how can the change be further improved. References Cherry, B. & Jacob, S. (2019). Contemporary Nursing: issues, trends & management. (8th edition). Elsevier. Institute for Healthcare Improvement (IHI). (2017). QI Essential Toolkit: Failure modes and effects analysis (FMEA) tool. Retrieved from: http://www.ihi.org/resources/pages/tools/failuremodesandeffectsanalysistool.aspx Institute for Healthcare Improvement (IHI). (n.d.). Patient Safety 104: Root Cause and System Analysis Summary Sheet. Retrieved from: https://srmc.na60.content.force.com/servlet/fileField?id=0BE0c000000LYai
