A Root Cause Analysis Essay

health c atomic number 18 facilities that be accredited by Joint Commission argon required after a observatory dis forge case to conduct a root run abbreviation (RCA). A root casing analysis is conducted to determine the cause or factors that contributed to the sentinel event. A few things must be asked in the RCA such(prenominal) as who, what, where, why and how in order to identify the cause. After the cause of the sentinel event is heady and a nonindulgent proceeding plan has been contrive in place a failure flair and effects analysis (FMEA) could be conducted to reduce the likelihood that it should happen again.The scenarioA 67 year aging male (Mr. B) was brought into the touch room for pain to left leg and left pelvis. The injury occurred when the long-suffering of had a f both overdue to him losing his balance after tripping over his dog. The hospital is a 60 spang rural hospital located in Mr. Bs hometown. Mr. B was brought in by his male child and neighbor. Upon triage Mr. B was complaining of pain 10/10 on the numerical pain scale and his vital organ were found to be stable. Mr. B has a history of impaired glucose tolerance, prostate cancer, and chronic pain which he is on oxycod iodin. The Patient states he had no known exclusivelyergies or previous f entirelys. Upon the breast feeding assessment protect J. has noticed that the forbearing has limited range in motion, his left leg has swelling and appears shortened in comparison to the right. harbor J. has informed the ED physician which he came to his bedside for evaluation. Upon evaluation the physician decided that Mr. B needed to have a decrease of his left hip, due to the dislocation and testament require a certified sedation. Mr. B requires multiple doses of medication to achieve the desired sedation affect for the reduction. Once the reduction was successful Mr. B is left with son in the room where a full set of vitals were not continuously monitoring deviceed and go es into respiratory failure which lead to the death of Mr. B. Staffing on this day is the day of the event consisted of a secretary, emergency surgical incision physician (Dr. T), and two nurses (one RN and one licensed practical nurse). A respiratory therapist is in house and available as needed in this six bed ED and cardinalbed hospital.EventsAt 330pm- Mr. B was taken to ED for left leg and left hip pain from a fall. Pain is a 10/10 vitals include 120/80 blood pressure (BP), 88 heart rate (HR) and regular, 98.6 temperature, (T), 32 respirations (R), 175 lbs.. At 405pm- Mr. B was given Diazepam 5mg IVP which had no affect after 5min. At 410pm- Dr. T orders 2mg of hydromorphone to be given to Mr. B. At 415pm- Mr. B was given 2mg of hydromorphone IVP.At 420pm- Dr. T is not satisfied with level of sedation and orders Mr. B to be given 2mg of hydromorphone, and diazepam 5mg IVP. At 425pm- Mr. B appears to be sedated and reduction of his (L) hip takes place. The uncomplaining remain s sedated and appears to have tolerated the mapping. The maps concludes at 430pm. No distress is noted, uncomplaining is primed(p) on monitor for blood pressure to be taken all(prenominal) 5 minutes along with pulse oximeter but no supplemental oxygen or cardiogram leads (monitors cardiac rhythm and respirations) was placed on long-suffering at this time. At 430pm- comfort J allows Mr. Bs son to remain in the room with him as he is macrocosm monitor by blood pressure machine only. Nurse J leaves the room. At 435pm- Mr. B vitals are BP 110/62, O2 sat is 92% still no oxygen or ECG leads are on patient at this time. EMS is transporting a patient in respiratory distress, lobby is beginning to find come on congested.LPN and Nurse J. in the exhibit of discharging 2 patients and are checking in the patient that EMS has transported in. LPN enters Mr. Bs room and resets his alarming monitor that was showing a sat of 85% and restarts the B/P to recycle. LPN does not supply oxygen and does not alert Nurse J at this time. way is not notified that patient sharpness and patient load is increasing. Nurse J is now fully occupied with the emergency care of the respiratory distress patient. At 443pm- Mr. Bs 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 palpable pulse and is not breathing. A STAT label is called and the son is taken to the waiting room.The code teams arrives places Mr. B on cardiac monitor where he is in ventricular fibrillation and the team begins resuscitative efforts. CPR is started and the patient is intubated. Mr. B is defibrillated and reversalagents, vasopressors and IV were started. At 513pm- After 30 min of interventions the ECG returns to a normal sinus rhythm with Mr. Bs B/P being 110/70. The patient is all overly dependent on the ventilator, his pupils are fixed and dilated and there is no spontaneous movements. The family as asked for the patient to be t ransferred out to a tertiary rapidity for further advanced care.Outcome heptad old age later Mr. B has died. The family had requested that life- congest be removed after brain death had been unflinching by EEGs. This is a sentinel event.Investigation of sentinel event should begin with a group and method of investigation. Interdisciplinary team included in the RCA should include the Director of Nurses, care for Supervisor, Risk management, Nursing Coordinator, and Manager of the department. Once the team is put together the RCA should be started. The team should set up interviews with all supply that was involved and present in the department the day the sentinel event happened. A complete chart review should be conducted by team.The policies on conscious sedation, staffing of department, and standardized work should be reviewed. When the cause is identified a corrective action plan should be conducted. The corrective action plan allow for allow a series of projects can be put in place to help hit or change polices if needed. The hot or changed polices should be put into education agencyls to t severally to current and new staff as needed.The Root Cause AnalysisCausative factors- (why it happened) determined causeIndividuals cause factorsNurse J did not follow social function for conscious sedation. The patient was not placed on continuous B/P, ECG, and pulse oximeter throughout the procedure. Respiratory Therapist was not informed of the conscious sedation. LPN did not address low o2 volume of 85% in the midst of the 435pm-443pm. Dr. T did not take in account of the patients weight and chronic pain medication use. Nurse J did not question the medication that Dr. T ordered.teams cause factorsManagement was not called and informed of staffing needs and acuity of patients. Back up staff was not called in to help when acuity and patient load had increased. Commination amid Nurses and Dr. T were not present when the patient began to decompensate.Manag ement /Organizational cause factorsUnsafe Staffing at ED. There was not enough staff present to safely manage emergencies in the ED. RCA FindingsErrors and/or Hazards1. Per protocol the patient was not hooked up to the beseeming monitoring equipment at the bedside. The facility procedure police called for continuous B/P ECG, and pulse oximetry during and after procedure until patient conglomerate the discharge criteria. The nurse should have remained with patient during the recovery period. Crash 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 notify Nurse J or ED physician when the patients o2 saturation dropped down to 85%. Oxygen was not placed on patient when O2 saturation dropped which led to respiratory failure causing the patient to code and eventually led to Mr. Bs death.3. Communication between ED staff and managem ent lacked when staffing needs increased. Patient guard duty was put at lay on the line when the patient load and acuity increased in the ED and the staffing did not increase. Staffing shortage caused the nurse and nursing put forward staff to attend to other patients and leave Mr. B unmonitored which led to respiratory distress due to the patient being over medicated for sedation which led to respiratory failure and eventually led to Mr. Bs death. 4. The ED physician did not request the patient be transferred to the nearest trauma center due to lack of recourses in the emergency department.Recommended Corrective Action Plan/Change surmise/Improvement Plan1. Improved patient safety during conscious sedation Effective immediately all conscious sedation procedures impart be conducted per protocol. Within 10 days the conscious sedation procedure should be measure outd by a committee to encounter the best put ons are being used. Within 30 days of this RCA allstaff should be educ ated on conscious sedation protocol. every last(predicate) 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 failure lies. This could be that the nursing support staff is unaware of the parameters that should be inform to nurse or physician. With 10 days of this RCA a policy on documentation of communication should be put in place to ensure that all nursing staff are documenting the communication of a patients change in status has be reported to physician.Effective 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 policy along with documentation of communication. 3. Improved patient to nurse ratios Management should put in place a safe nurse to patient ratio for the emergen cy room. Communication policy between department and management should be put in place effective immediately to ensure that no other patient should be placed in defames way 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 manner. A copy of the RCA should be given to management and leadership. Management should make out the finding with all emergency department staff.Feedback 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 improve patient safety. Constant reevaluation of patient safety should be conducted and feedback given to improve patient safety by all providers involved. Management will track 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 abidance and effectiveness is still in place and reevaluate the process to ensure patient safety. nonstarter way of life and Effects Analysis (FMEA)A Failure Mode and Effects Analysis is proactive versus the RCA which is reactive. A FMEA assesses a process for risks of failures or adverse effects of a process and prevents them by correcting what is wrong proactively(Institute for Heathcare Improvement, 2004). A health care facility may use FMEA tools on the Institute for Healthcare Improvement website to evaluate a process in the facility. This tool will calculate a risk priority number (RNP) of a process, evaluate the impact of the process and the changes that are being considered, and tract the improvement over time (Institute for Heathcare Improvement, 2004).PRE-FMEA1. touchstone one Select a process to be evaluated with FMEA. The FMEA for this paper will focus on the conscious sedation protocol. 2. Step Two 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 will include.Registered NursePhysicianManagementPharmacistRespiratory therapistA member from LegalLaboratory techEmergency Department Tech3. Step Three Information needs to be gathered by the team. A advert of pure tones in the process being evaluated should be put together or even an outline of tone of voices would be helpful to the team. All internal and external entropy, clinical practice guidelines, current policies and procedures, current literature and any other information that may pertain to the process that is being evaluated. For the purpose of this paper we would use data on outcomes of conscious sedation protocols, RCAs on no-count outcomes, clinical practice guidelines and any research documentation that would aid in best practices for conscious sedation.Team meet ings should be structured with an agenda. A leader or primary person with extensive intimacy of the FMEA knowledge (Department of defense mechanism Patient Safety Center, 2004) 4. Step Four The Team should list the failure modes and causes. In each process all failure modes should be listed, and then for each failure mode a list of assertable causes should be listed as well. In this scenario we will use this as an examplePreparing medication incorrectly medication vigilant rail at dose prepared5. Step Five A Risk precession Number (RPN) will be assigned to each failure mode for the likelihood of occurrence, for the likelihood of detection, and for the clumsiness. This step is also known as the three steps FMEA. The RPN is a numerical rating. For this scenario here is an example likeliness of Occurrence This will measure the likelihood a failure mode is to occur. The score range will be 1-10 with 1 center it is very un in all likelihood to occur and 10 meaning very likely to occur. Example- Wrong medication prepared = 5Likelihood of Detection This will measure the likelihood a failure mode is to be detected if it should occur. The score range will be 1-10 with 1 meaning it is very likely to be detected and 10 meaning very unlikely to be detected. Example- Wrong medication prepared = 6Severity of occurrence This will measure the severity 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= 96. 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 PreparedOccurrence- 5Detection- 6Severity- 95x6x9 = overall score =2707. Step Seven An improvement plan will be made based on the RPN. Likely to Occur. Have a triple check put in place. Have 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.Unlikely to be detected.Look for warning signs that the error may not be detected.Use data from any previous or prior errors.Severity.Use any data available to determine severity of error.Make available any and all resources to prevent further errors and severity of errors.Final 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 form all obser vations 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.All changes or modifications to the process will be based on the test and analysis of data conducted. any and all changes should be communicated to all staff members. These changes may or may not show improvement to the process, this is why constant reevaluation of all process should be conducted and any feedback should be given to leadership for the reevaluation of the process.Nurses play a vital role in health care. Nurses have the most contact with a patient. Nurses canalize 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 looking for evidence base practices to improve patient care and patient safety. Improving quality of care for each pati ent will improve the outcomes for each patient.ReferencesDepartment of Defense Patient Safety Center. (2004, 12 26). Failure Mode and Effects Analysis. Retrieved from FMEA Info Centre 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