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Organizational Systems and Quality Leadership Task 2 Western Governors University A. Root Cause Analysis (RCA) Root Cause Analysis (RCA) is a tool used within healthcare to aid in the discussion and prevention of errors that may have happened. A group of individuals discusses what and why a situation occurred but also helps to formulate a plan in which to prevent it from happening again instead of focusing on who was involved. Root Cause Analysis has an aim to “build a culture of safety and move beyond the culture of blame” (U.S. Department of Veterans Affairs, n.d.). By further looking into how and why events occur healthcare systems are better equipped to prevent future incidences from occurring. A1. RCA Steps Step One: Identify what happened The panel must determine what exactly took place and in doing so must also make sure that all details are included and accurate. To better understand the information flowcharts or pictorials are often used to aid in the visualization of the event. Step Two: Determine what should have happened The panel will then discuss what should have happened to achieve the optimal results. In this stage, another flowchart can be used with the correct policies or procedures listed so that the team may look at the chart from step one and compare. Step Three: Determine the cause
During this step, the team looks at factors that lead to the error both directly and contributory. A fishbone diagram is often used during this phase of the process to better visualize the cause and effect flow. RCAs recommend asking “why” repeatedly to determine the exact cause of the problem being discussed. Step Four: Develop causal statements The main purpose of developing a causal statement is to add links between the cause that was determined in step three to the outcome and then back to the main event that initiated the RCA. These statements give explanations on how events arose and aid in the implementation of changes to policies and procedures to prevent future incidences. Step Five: Create a checklist of recommended actions to avert repeating the issue Create a list of actions to aid in the prevention of recurrence of the event being discussed. Included in this list can be issues such as simplifying processes, the use of a checklist, standardizing policies, and also repeating procedures to ensure compliance. Timelines should be created to determine if policy changes are effective or if further revisions are necessary. Recommendations for change may include: Standardizing equipment Ensuring repetition (using backup systems/double checks) Improving/updating software Making new policies Employing hard stops which aid to hinder users from making repeated errors Continued staff training Providing aids such as mnemonic devices, illustrations, and lists Establishing new policies
Having not monitored Mr. B’s O2 levels there was not a baseline to compare to if an adverse reaction occurred. Supplemental oxygen was never provided to Mr. B before, during, or after medications were administered. Due to the strong sedative medications being administered Mr. B should have been on supplemental oxygen therapy, continuous blood pressure/pulse oximetry monitoring, and ECG monitoring and a nurse should have stayed at the bedside until it was determined that he was stable. According to the scenario, however, none of these policies or procedures were followed all of which could have signaled deteriorations in Mr. B’s vital signs due to the sedatives administered. The last error noted within the scenario occurred when the LPN assigned to Mr. B failed to report to the RN oxygen levels reading at 85% saturation. With the proper report of critical information, the RN providing care to Mr. B could have gone to the bedside and placed him on supplemental O2 while providing an additional assessment of the patient to determine the cause. As stated in the scenario the RN was extremely busy and the unit was understaffed which appeared to be a large contributing factor to the situation at hand. The scenario did state that a respiratory therapist was staffed and with proper training, the LPN could choose to consult with them to determine what steps needed to be taken at this time to prevent further deterioration. Per the scenario, at the time of the incident, the ED was staffed with one RN and one LPN and there were a total of 3 patients with another to be admitted. Failure of the ED staff to call for backup was a tremendous contributing factor that leads to the sentinel event in question. B. Improvement Plan The first step in the improvement plan is to establish a team. For this particular plan in discussion the team may consist of the director of the ED, someone from the risk management department, the director of nursing, a respiratory therapist team member, and also a charge nurse
or staff member from the ED. The next in the process is to determine exactly what happened as thoroughly as possible by interviewing those involved in the incident. Along with interviews, charting can be reviewed to create a detailed flow chart of all events that took place based on all information collected. Upon reviewing this information the team can then determine what should have occurred to prevent this event from transpiring. The team can then construct another flow chart based on this information to have a side-by-side comparison of the events that took place and those that should have occurred. At this point, the team will also ask “why” repeatedly to determine the exact cause of the events in question. Next, a causal statement is formed by the team which discusses the cause, effect, and event. The fifth step in the process would be coming up with suggestions to aid in the prevention of future occurrences of the problem at hand. Lastly, the team will formulate a synopsis of the RCA and disburse it to management, staff, investors, and other colleagues. Provided in the synopsis could be recommended safety checklist for the administration of sedatives to make sure important vital sign monitoring takes place and also proper staffing ratios with the use of flex/float pool nurses during busy times. B1. Change Theory In 1950 Kurt Lewin developed a tool in which to aid in change management. Lewin’s change theory was made up of three steps. The first step in the process is to unfreeze in which things are set up to prepare for the change desired. The second is titled change and this is where the necessary changes are set in motion. Lastly, is refreeze where you solidify the desired change (Mulder, 2012). In the unfreezing phase, awareness is brought to the change in question to help people understand why this particular change is necessary. The process improvement team should educate employees about the sentinel event and what policies/procedures lead to this occurrence,
detection, and how severe the failure was. In the last step in the process, the team then evaluates the RPN to plan for improvement. C2. FMEA Table See additional attachment for the table. D. Intervention Testing The improvement process has tested the suggestions for change must first be implemented. The changes that must be made are staffing ratios, medication safety, and proper vital sign monitoring. Random chart analysis can be performed to determine if checklists are being used as recommended in the change. Upon review, if it is determined that checklists are not being used as recommended then modifications can be made. This process is then repeated until it is determined that proper usage is occurring. When assessing staffing ratios, charts can be made to monitor and determine when the ED experiences the highest volume of patients. In doing this there will be a better understanding of the staffing needs to avoid possible negative events from occurring while increasing patient and staff satisfaction at the same time. E. Demonstrate Leadership Promoting Quality Care Promoting quality care can be demonstrated in the leadership of professional nurses by improving the standards of care. Quality of care occurs when the proper policies are in place and when the nurses are held to these policies. Nurses can help formulate and rewrite current policies based on continued research and evidence-based practice skills to improve patient quality of care.
Improving Patient Outcomes Improving patient outcomes is one of the top priorities of a professional nurse’s practice. Nurses are the front-line workers and should be able to pick up on indicators that signal a possible decline in the patient’s health. As a professional nurse leader, it is important to make sure that other nurses are also playing their part in the improvement of patient outcomes. Influencing Quality Improvement Activities Professional nurses can also be leaders within their field by helping to influence quality improvement activities. This can be achieved by giving fellow nurses a voice in policies that are not working or that could be changed to work more efficiently. Additionally, the nurse can research and carry out studies on the quality of healthcare being offered and implement new policies in which to further improve this area. E1. Involving Professional Nurse in RCA and FMEA Processes The involvement of professional nurses in the RCA and FMEA processes is crucial to gaining access to viewpoints that would otherwise not have and could greatly impact the approaches for necessary changes needed. It allowing nurses to be active participants in this process they are given a voice in the way in which they practice and can be beneficial in creating and setting modifications in practices used. Nurses see the big picture instead of just small portions of things occurring which aids in preventing further negative events from occurring. References Colin, J. L. McCartney, Ahtsham Niazi. (2006). Use of opioid analgesics in the perioperative period. Retrieved from http://www.sciencedirect.com/topics/medicine-and-
