'A Root Cause Analysis Essay\r'

'Healthcargon facilities that argon genuine by Joint Commission argon required subsequently a piquet event to conduct a stand run analysis (RCA). A locate f be analysis is conducted to determine the let or factors that contributed to the sc aside event. A few things must be asked in the RCA much(prenominal) as who, what, w here(predicate), why and how in assign up to identify the ca occasion. aft(prenominal)(prenominal) the cause of the vigil event is hardened and a disciplinary action invent has been directionl in consecrate a bankruptcy flair and effectuate analysis (FMEA) could be conducted to mortify the likelihood that it should happen again.\r\nThe scenario\r\nA 67 year old male (Mr. B) was brought into the essential dwell for upset to left-hand(a) phase and left pelvis. The injury occurred when the unhurried had a f each c whatsoeverable to him losing his balance after tripping e realwhere his dog. The infirmary is a 60 tail end rural hospit al located in Mr. B’s hometown. Mr. B was brought in by his watchword and neighbor. Upon triage Mr. B was complaining of disquiet 10/10 on the numerical pain scale and his vital organ were found to be stable. Mr. B has a history of stricken glucose tolerance, prostate bottomlandcer, and chronic pain which he is on oxyco through with(p). The persevering states he had no k like a shotn each(prenominal)ergies or former f whollys. Upon the treat assessment obtain J. has noniced that the affected role has limited thread in motion, his left leg has swelling and appears shortened in comparison to the right.\r\n absorb J. has informed the ED medical student which he came to his bedside for evaluation. Upon evaluation the physician decided that Mr. B needed to pick up a reduction of his left hip, due to the dislocation and date require a sure drugging. Mr. B requires multiple dots of medicinal drug to achieve the desired sedation f every(prenominal) for the redu ction. Once the reduction was successful Mr. B is left with son in the modal value where a full set of vitals were non continuously proctor lizarded and goes into respiratory ruin which lead to the death of Mr. B. Staffing on this twenty-four hours is the mean solar day of the event consisted of a secretary, tinge discussion section physician (Dr. T), and two decl atomic government issue 18s ( sensation RN and one LPN). A respiratory therapist is in house and available as needed in this six bed ED and sixty\r\nbed hospital.\r\nEvents\r\nAt 3:30pm- Mr. B was taken to ED for left leg and left hip pain from a f only. Pain is a 10/10 vitals overwhelm 120/80 blood shove (BP), 88 heart rate (HR) and regular, 98.6 temperature, (T), 32 respirations (R), 175 lbs.. At 4:05pm- Mr. B was addicted Diazepam 5mg IVP which had no affect after 5min. At 4:10pm- Dr. T orders 2mg of hydromorphone to be habituated to Mr. B. At 4:15pm- Mr. B was given 2mg of hydromorphone IVP.\r\nAt 4:20pm- Dr. T is non satisfied with level of sedation and orders Mr. B to be given 2mg of hydromorphone, and diazepam 5mg IVP. At 4:25pm- Mr. B appears to be sedated and reduction of his (L) hip takes prep atomic number 18. The enduring dust sedated and appears to have tolerated the performance. The un apprised procedures concludes at 4:30pm. No mourning is noned, enduring is fit(p) on observe for blood pressure to be taken every 5 minutes along with thrill oximeter but no supplemental oxygen or electrocardiogram leads (monitors cardiac rhythm and respirations) was move on tolerant of at this time. At 4:30pm- Nurse J allows Mr. B’s son to remain in the room with him as he is existence monitor by blood pressure railcar only. Nurse J leaves the room. At 4:35pm- Mr. B vitals are BP cx/62, O2 sat is 92% still no oxygen or ECG leads are on affected role at this time. EMS is transporting a long-suffering in respiratory distress, manse is arrivening to get congeste d.\r\nLPN and Nurse J. in the puzzle out of discharging 2 forbearings and are typeseting in the tolerant that EMS has transported in. LPN enters Mr. B’s room and resets his horrify monitor that was showing a sat of 85% and restarts the B/P to recycle. LPN does non supply oxygen and does non watchful Nurse J at this time. guidance is non notified that affected role raciness and enduring extend is increasing. Nurse J is now fully engaged with the emergency premeditation of the respiratory distress patient. At 4:43pm- Mr. B’s son comes out of room and informs the nurse that the monitor is alarming with vitas of B/P 58/80 O2 of 79%. The patient has no open pulse and is not breathing. A STAT mandate is cal guide and the son is taken to the waiting room.\r\nThe principle squads arrives push throughs Mr. B on cardiac monitor where he is in ventricular fibrillation and the squad begins resuscitative efforts. CPR is started and the patient is intubated. M r. B is defibrillated and gust agents, vasopressors and IV were started. At 5:13pm- After 30 min of interventions the ECG returns to a normal sinus rhythm with Mr. B’s B/P organism 110/70. The patient is arrestly leechlike on the ventilator, his pupils are fixed and dilated and there is no spontaneous movements. The family as asked for the patient to be transferred out to a 3rd installment for further advanced care.\r\n military issue\r\n seven just about Days after Mr. B has died. The family had inviteed that life- software documentation be distant after brain death had been determined by EEG’s. This is a sentinel event.\r\nInvestigation of sentinel event should begin with a squad up and method of investigation. interdisciplinary team overwhelmd in the RCA should include the Director of Nurses, nurse Supervisor, Risk commission, Nursing Coordinator, and Manager of the department. Once the team is move together the RCA should be started. The team should set up interviews with all faculty that was twisting and indue in the department the day the sentinel event happened. A complete chart review should be conducted by team.\r\nThe policies on conscious sedation, rounding of department, and standardized bleed should be reviewed. When the cause is identified a restorative action project should be conducted. The corrective action plan pass on allow a series of projects can be spue in place to help create or deepen polices if needed. The new or interchanged polices should be put into education models to teach to rate of flow and new faculty as needed.\r\nThe Root typeface synopsis\r\nCausative factors- (why it happened) determined cause\r\nIndividual’s cause factors\r\nNurse J did not follow social function for conscious sedation. The patient was not placed on continuous B/P, ECG, and pulse oximeter throughout the act. Respiratory Therapist was not informed of the conscious sedation. LPN did not address low o2 fe cundation of 85% between the 4:35pm-4:43pm. Dr. T did not take in account of the patient’s weight and chronic pain practice of medicine use. Nurse J did not question the medication that Dr. T ordered.\r\n police squad’s cause factors\r\n counseling was not called and informed of staffing demand and acuity of patients. back down up staff was not called in to help when acuity and patient load had increased. Commination between Nurses and Dr. T were not present when the patient began to decompensate.\r\n heed /Organizational cause factors\r\nUnsafe Staffing at ED. There was not enough staff present to safely manage emergencies in the ED. RCA Findings:\r\nErrors and/or Hazards\r\n1. Per communions protocol the patient was not hooked up to the comme il faut monitoring equipment at the bedside. The facility procedure police called for continuous B/P ECG, and pulse oximetry during and after procedure until patient run into the discharge criteria. The nurse should have remained with patient during the recovery period. take apart cart with defibrillator was not present during the procedure nor was the proper reversal agents that could reverse the medication given for sedation. 2. Nursing staff communication was very poor. LPN did not suggest Nurse J or ED physician when the patient’s o2 colour dropped down to 85%. Oxygen was not placed on patient when O2 saturation dropped which led to respiratory hardship causation the patient to code and eventually led to Mr. B’s death.\r\n3. talk between ED staff and trouble lacked when staffing needs increased. Patient gumshoe was put at try when the patient load and acuity increased in the ED and the staffing did not increase. Staffing shortage caused the nurse and nursing deport staff to attend to other patients and leave Mr. B unmonitored which led to respiratory distress due to the patient world over medicated for sedation which led to respiratory mischance and eventually led to Mr . B’s death. 4. The ED physician did not request the patient be transferred to the nearest suffering center due to lack of holiday resort’s in the emergency department.\r\nRecommended tonic Action Plan/Change conjecture/Improvement Plan\r\n1. Improved patient safety during conscious sedation: sound direct all conscious sedation procedures provide be conducted per protocol. Within 10 days the conscious sedation procedure should be evaluated by a citizens committee to stop up the best normals are being used. Within 30 days of this RCA all staff should be educated on conscious sedation protocol. All nursing staff should use review protocols for conscious sedation before a conscious sedation procedure is to take place. 2. communication within the department should be evaluated immediately by a group of staff members to find out where the miscommunication visitation lies. This could be that the nursing support staff is unaware of the parameters that should be re ported to nurse or physician. With 10 days of this RCA a constitution on documentation of communication should be put in place to go through that all nursing staff are documenting the communication of a patients change in status has be reported to physician.\r\n useful immediately all nursing support staff should be educated on parameters that should be reported to nursing staff and physicians. This should be put into a constitution along with documentation of communication. 3. Improved patient to nurse ratios: Management should put in place a safe nurse to patient ratio for the emergency room. Communication policy between department and management should be put in place effective immediately to catch that no other patient should be placed in terms’s authority due to staffing shortage. The emergency department should be put on diversion if the patient load and acuity places patients at risk for harm in any(prenominal) manner. A copy of the RCA should be given to manage ment and drawship. Management should share the finding with all emergency department staff.\r\nFeedback should be done 30 days after corrective action plan or change theory have been put in place to ensure that everything that has been put in place is effective for the department to change patient safety. Constant reevaluation of patient safety should be conducted and feedback given to improve patient safety by all providers involved. Management allow continue to ensure that all staff follow all protocols to ensure that patient care and safety are not compromised. At a 90 days bench mark after the corrective action plan has been put in place management should revisit the any changes made to protocols and polices to ensure shape and effectiveness is still in place and reevaluate the dish out to ensure patient safety.\r\n nonstarter Mode and effectuate synopsis (FMEA)\r\nA Failure Mode and Effects Analysis is proactive versus the RCA which is reactive. A FMEA assesses a process for risks of trials or adverse effects of a process and prevents them by correcting what is ill-timed proactively (Institute for Heathcare Improvement, 2004). A healthcare facility whitethorn use FMEA tools on the Institute for Healthcare Improvement website to evaluate a process in the facility. This tool allow for drive a risk priority number (RNP) of a process, evaluate the impact of the process and the changes that are being considered, and tract the melioration over time (Institute for Heathcare Improvement, 2004).\r\nPRE-FMEA\r\n1. tone of voice one: Select a process to be evaluated with FMEA. The FMEA for this paper leave alone focus on the conscious sedation protocol. 2. Step dickens: Recruit a multidisciplinary team and include a member from every department that may be involved or affected. This team for the conscious sedation protocol should entrust include.\r\nRegistered Nurse\r\nPhysician\r\nManagement\r\nPharmacist\r\nRespiratory therapist\r\nA member from Legal\r\nLaboratory tech\r\nEmergency Department Tech\r\n3. Step Three: Information needs to be gathered by the team. A enumerate of bars in the process being evaluated should be put together or even an outline of steps would be helpful to the team. All internal and outside info, clinical practice guidelines, current policies and procedures, current literature and any other breeding that may pertain to the process that is being evaluated. For the purpose of this paper we would use entropy on outcomes of conscious sedation protocols, RCA’s on bad outcomes, clinical practice guidelines and any research documentation that would promote in best practices for conscious sedation.\r\n police squad meetings should be structured with an agenda. A leader or primary person with ample knowledge of the FMEA knowledge (Department of falsification Patient Safety Center, 2004) 4. Step Four: The Team should list the distress modes and causes. In each process all failure modes shoul d be listed, and then for each failure mode a list of viable causes should be listed as well. In this scenario we will use this as an example\r\nPreparing medication\r\n molest medication prompt\r\n awry(p) dose prepared\r\n5. Step Five: A Risk Priority Number (RPN) will be assigned to each failure mode for the likelihood of occurrence, for the likelihood of detection, and for the grimness. This step is also known as the tierce steps FMEA. The RPN is a numerical rating. For this scenario here is an example Likelihood of Occurrence: This will measure the likelihood a failure mode is to occur. The score range will be 1-10 with 1 convey it is very un liable(predicate) to occur and 10 nub very likely to occur. Example- Wrong medication prepared = 5\r\nLikelihood of staining: This will measure the likelihood a failure mode is to be discover if it should occur. The score range will be 1-10 with 1 core it is very likely to be detected and 10 meaning very unlikely to be detected. E xample- Wrong medication prepared = 6\r\n inclemency of occurrence: This will measure the rigour of the failure mode should it occur. The score range will be 1-10 with 1 meaning no effect and 10 will be death should a failure mode occur. Example- Wrong medication prepared= 9\r\n6. Step Six: The team will evaluate the results. For each failure mode the three scores are multiplied with each other. The failure mode with the highest RPN will be the one that will be evaluated by the team to ensure patient safety. The higher the RPN a failure mode has the higher the potential for harm it may cause. The RPN score can be as high as 1,000 and as low at 3. Example- Wrong medication Prepared\r\nOccurrence- 5\r\nDetection- 6\r\nSeverity- 9\r\n5x6x9= overall score =270\r\n7. Step Seven: An improvement plan will be made based on the RPN. probable to Occur. affirm a triple check put in place. down team attempt to eliminate all possible causes. Example-Have medication scanned when pulled from Pyxis to check providers order. Have patient scanned before medication may be prepared to check providers order. Have patient and medication scanned to ensure correct patient with the correct medication and proper providers order.\r\nUnlikely to be detected.\r\nLook for example signs that the error may not be detected.\r\nUse data from any previous or prior errors.\r\nSeverity.\r\nUse any data available to determine severity of error.\r\nMake available any and all resources to prevent further errors and severity of errors.\r\n last-place Step- The final step in the FMEA is to plan an observation or test. A plan should be clear of its objections and should have some sort of predictions or outcomes. During the test all data should be documented. In this data collection phase all observations including problems or unexpected issues should be documented and later evaluated. After the test is complete and all data collected the team should meet for analysis of the data. A summary of the analysis should be documented.\r\nAll changes or modifications to the process will be based on the test and analysis of data conducted. every and all changes should be communicated to all staff members. These changes may or may not show improvement to the process, this is why uniform reevaluation of all process should be conducted and any feedback should be given to leadership for the reevaluation of the process.\r\nNurses wanton a vital role in health care. Nurses have the most tie with a patient. Nurses carry out any orders and or processes. A nurse is the patient advocate, they are the ones who will advocate for patient safety. Nurses are the advocates who will be feeling for evidence base practices to improve patient care and patient safety. Improving tone of care for each patient will improve the outcomes for each patient.\r\nReferences\r\nDepartment of Defense Patient Safety Center. (2004, 12 26). Failure Mode and Effects Analysis. Retrieved from FMEA Info ticker: http: //www.fmeainfocentre.com/handbooks/FMEA_Guide_V1.pdf Institute for Heathcare Improvement. (2004). Failure Modes and Effects Analysis (FMEA). Retrieved from Institute for Heathcare Improvement: http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx\r\n'