Root cause analysis responding to a sentinel event

Root Cause Analysis Fema Paper

Organizational Systems and Quality Leadership

Task 2: RCA AND FMEA

Brenna Steighner

February 4, 2020

Western Governors University

Explain the general purpose of conducting a root cause analysis (RCA).

A root cause analysis (RCA) is a process for classifying the cause of a problem, and then a good way to approach and respond to the problem. The goal is to examine what happened, how the issue happened, and why it happened so that actions can be put into place to prevent a reoccurrence from happening (Institute for Healthcare Improvement).

Explain each of the six steps used to conduct an RCA, as defined by IHI.

Most often and RCA team involves four to six individuals from a mix of different professions. Each person should have fundamental knowledge of the problems and procedure involved in the accident. There is a total of six steps. The first step is to identify what happened. The team needs to explain what happened by organizing the information to clarify exactly what took place. The second step is to determine what should have happened. The team can create a chart to better understand what should have happened in an ideal situation. Number three is to determine causes (“Ask why five times”). This is how the team determines the factors that lead to the event. They look at the direct causes and the contributory factors as to why the incident happened. The fourth step is to develop causal statements. This is how they explain how the contributory factors lead to the bad outcomes. Step number five is to generate a list of recommended steps to prevent the recurrence of the event, which are changes that the team thinks will aid in preventing the error from happening again. The final sixth step is, write a summary and share it. This can help to engage people to aid in the steps of improvement (Institute for Healthcare Improvement).

Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome.

The first step is to identify what happened: Mr. B is a 67-year-old male who is 175lbs with a past medical history of, chronic back pain which he was taking oxycodone for, impaired glucose tolerance, prostate cancer, high cholesterol, and high triglycerides. He was brought to the Emergency department (ED) by his son and neighbor complaining of pain in the left leg and left hip. He states he lost balance and tripped over the dog causing him to fall. When he had arrived at the ED, his blood pressure, heart rate and temp were all within normal limits, and his respirations were noted to be elevated at 32 which could be from the severe pain he was experiencing, which he rated 10/10. He was noted to have shortening of the left leg, edema, ecchymosis, and limited range of motion. There were two nurses (an LPN and an RN), an ER doctor, one secretary, and hospital respiratory therapist on staff at this rural hospital. Mr. B was the third patient in the ER at the time of arrival. The doctor evaluated Mr. B and ordered the RN to give 5mg of diazepam IV push, when that did not have an effect after 5 minutes the doctor then ordered the RN to give Hydromorphone 2mg IV push which was given 10 minutes later. The doctor was still not happy with the results after 5 minutes so, he then ordered to give another 2mg of Hydromorphone and an additional 5mg of diazepam both IV push. The sedation goal of the doctor was finally achieved, and he performed a reduction of the left hip. The patient had tolerated the procedure and he was still sedated, without any supplemental oxygen placed. The ED was then notified of a patient on the way in for acute respiratory distress, so the nurse put the patient on an automatic blood pressure and pulse oximeter reading every 5 minutes and she left the room leaving the son to sit with the patient. Five minutes after the procedure had ended the patients blood pressure had decreased to 110/62 and his oxygen saturation decreased to 92%, remaining without supplemental oxygen, and without ECG and respiration monitoring. While the RN and LPN were occupied with the new arrival, Mr. B’s oxygen monitor was alarming to indicate his oxygen had dropped to 85%. Then Mr. B’s son came out to alarm the nurse that the monitor was ringing again, she finally entered the room to find his blood pressure at 58/30 and oxygen level at 79%, Mr. B had no signs of breathing and there was no palpable pulse. The nurse called a STAT code and resuscitative efforts were started, he was intubated, defibrillated, given reversal agents, given IV fluids, and given vasopressors. This lasted 30 minutes, the ECG returned to normal sinus rhythm, blood pressure was 110/70. Mr. B was fully dependent on the ventilator, his pupils were fixed and dilated, and he was not responding to stimuli. Mr. B was then transferred to a different hospital for care upon the families wishes. Seven days after this ER visit, Mr. B was given a “brain dead” diagnosis, the family decided to remove life support and Mr. B had passed away.

The second step is to identify what should have happened. The doctor and nurse needed to be trained on the conscious sedation protocols in place, as well as known the proper dose and proper drugs to be used in this situation. If the nurse knew the drug dosing, she should have questioned the medication that was ordered to give to this patient. The nurse should of abided by the hospital protocol and placed the patient on continuous blood pressure, ECG, and pulse oximeter reading throughout the procedure and until the patient meets the criteria for discharge which was, being fully awake, vital signs being stable, no nausea or vomiting, and able to void. When Mr. B’s oxygen saturation was dropping the LPN should have notified the RN, instead she just silenced the alarm from going off which defeats the purpose of the alarm. Finally, the ER should have called for additional nurses and staff to assist with the current patients to prevent any accidents from happening.

The third step is to determine the causes of the event. The direct cause of death would be the irreversible brain damage due to lack of oxygen for a prolonged period of time. The the contributory factors to the patient’s death would be the lack of staffing, the doctor over sedating the patient for the procedure, not adhering to the protocol for proper conscious sedation monitoring, and ignoring the patients alarm for low oxygen saturation.

Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome.

The first thing that I would propose as an improvement plan to prevent a reoccurrence of this scenario is to conduct a mandatory training for the physicians, RNs, LPNs, and Respiratory Therapist regarding the conscious sedation protocol, that way everyone has the information needed including how to monitor, and what vitals to be monitoring. Then the only ones available to care for a patient that requires conscious sedation would be the ones who have successfully completed the training. I would propose to upper management that patients who have undergone conscious sedation require mandatory one on one monitoring until the criteria is met.

Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan.

The Lewin’s change theory has three steps; including unfreeze=change=refreeze. Individuals are not open to change, they get comfortable with their routine and tend to resist any change. However, revealing that there is a problem in the system requires the proper steps to change and make things more effective. In this scenario the staff need to be aware of the issues that have taken place, and then convinced of the benefits of change to them as well as the patient. Hosting a meeting to discuss the event and what took place and what needs to take place to improve care and prevent this from reoccurring. Change is not easy for anyone but taking the proper approach to initiate the change, provide support for the change, and then monitor to make sure the change is being used will make it easy for everyone in this process (Mind Tools, 2019).

Explain the general purpose of the failure mode and effects analysis (FMEA) process.

The Failure Mode and Effects Analysis (FMEA) is a step by step approach to identify possible problems before they occur. It is used to take action in reducing and eliminating failures. They also document the current knowledge about the risk of failures to continue improvements (Institute for Healthcare Improvement, 2020).

Describe the steps of the FMEA process as defined by IHI.

The first step of the FMEA process identified by the IHI is, define the scope and topic of the FMEA. The second step is to assemble a multi-disciplinary team of involved professionals. The third step is charting the steps of the process. The fourth step is hazard analysis which the team analysis completes the chart showing all the possible ways the process could fail, which includes the likelihood and severity. The fifth and final step is uses risk profile numbers (RPNs) to plan improvement, which identifies ways to keep the high-risk plans from failing (Institute for Healthcare Improvement, 2020).

Complete the attached FMEA table by appropriately applying the scales of severity, occurrence, and detection to the process improvement plan proposed in part B.

List 4 steps in your Improvement Plan Process

List 1 Failure Mode per step

Likelihood of Occurrence (1–10)

Likelihood of Detection (1–10)

Severity

(1–10)

Risk Priority Number

(RPN)

1. All physicians, RNs, LPNs, and Respiratory therapist do mandatory conscious sedation training

The protocol will not be followed as directed

6

7

6

252

2. Utilizing continuous O2 monitoring during and after the conscious sedation procedure until criteria is met

staff may take off monitor prior to criteria being met

7

6

9

378

3. Monitoring Blood pressure, and pulse before, during and after procedure

The patient’s vitals will fall or rise into abnormal values

6

4

8

192

4. Nurses and Doctors need to have mandatory training on medication to give for conscious sedation procedures

They will not abide by the medication administration rules in place causing patients to be at risk

8

6

10

480

Total RPN (sum of all RPN’s): 1,302

Explain how you would test the interventions from the process improvement plan from part B to improve care.

To test the interventions from the process improvement plan, there would need to be intense monitoring taking place to confirm that the staff are complying. There would need to be someone conducting a chart review of patients who underwent conscious sedation to show and prove that the staff is using the new policies and procedures. Analyzing these patients’ vital signs to measure improvement and compliance as well. Supervisors could do random checks to make sure staff are abiding by the protocols.

Explain how a professional nurse can competently demonstrate leadership in each of the following areas:

• promoting quality care – Professional nurses can demonstrate leadership in promoting quality of care by advocating for the patient. Some of the patients are in their most vulnerable state, and if the nurse is listening to their concerns and speaking up for them when needed if the patient is at a compromised state then this is giving quality care to that patient.

• improving patient outcomes- Professional nurses can demonstrate leadership in improving patient outcomes by adhering to the set protocols to ensure patient safety. The nurse should always have the patient’s best interest at heart so providing compassionate, caring, safe care should improve patient outcomes, so they feel they are taken care of in the best way possible.

• influencing quality improvement activities- Professional nurses can demonstrate leadership in influencing quality improvement activities by constantly educating yourself and evolving with the standards of care. As a nurse leader you will have the quality indicators examined regularly and be ready to change as needed.

Discuss how the involvement of the professional nurse in the RCA and FMEA processes demonstrates leadership qualities.

The professional nurse should be involved in the RCA and FEMA processes because they are a part of the team. Nurses should implement and evaluate plans and processes continuously. As a nurse you are constantly using your critical thinking skills to best assist the patient and you are an advocator for the patients. So, if you are involved in these two processes most likely patient outcomes will be improved because nurses are on the forefront of patient care.

References

Institute for Healthcare Improvement. (2020). Failure Modes and Effects Analysis( FMEA) Tool. Retrieved

from http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx

Institute for Healthcare Improvement. Patient Safety 104: Root Cause and Systems Analysis. Retrieved

on February 4, 2020 from app.ihi.org/LMS/Content/f99b4ea2-aeea-432d-a3573ca88b6ae886/Upload/PS%20104%20SummaryFINAL.pdf

Mind Tools. Lewin’s Change Management Model – Understanding the Three Stages of Change

(October 5, 2019) Retrieved from https://www.mindtools.com/pages/article/newPPM_94.htm