Organizational Systems and Quality Leadership

The health care facilities and institutions are always in search of effective measures to improve the errors identified in the evaluation plans. There are numerous tools that are essentially useful in the evaluation process using the data processing approach for meaningful change in the facility performance, quality and safety of health services. One critical tool useful in such evaluation is the Root Cause Analysis (RCA) tool that is normally used to assess challenges in a facility through a deeper problem assessment mechanism (Institute for Healthcare Improvement, 2018). The RCA tool assesses data gathered from different organizational department. A1. In addition, there are seven factors attributed to medical errors or practice challenges that must be considered comprising of individual staff member, institutional contexts, task factors, organizational challenges, team factors, work environment, , patients characteristics as well as management factors.

In the fourth step (Step Four), the team has the responsibility of overseeing casual statements for the RCA. These casual statements allows the team to focus on specific contributing factors and their consequences in the health system inefficiency or ineffectiveness. Step Five concerns the listing of the team recommendations that are appropriate in correcting or remedying the situation and preventing its reoccurrence in future. These recommendations could range from medical equipment upgrade, staff training programs, changes in policies and procedures or evidence-based interventions. Upon admission, he was checked by the ER doctor on Thursday 3. 30am who found that the patient was in moderate distress. There was inflammation on the troubled left leg that was inflamed with an edema traced at the calf.

Upon the nurse checking on the patient’s treatment history, it was established that despite the condition of the patient being normal, he was previously treated of oxycodone for chronic back pain, and on atorvastatin for high cholesterol and lipids. At 4. The two assigned nurses in the ER attended to the new patient as two more other patients were awaiting discharge orders from the facility. At the time, the nurses were alerted by the alarm sounds of Mr. B’s saturation of oxygen where the LPN in charge rushed to check his oxygen saturation level. The alarm was then reset by the LPN and took the readings of his blood pressure. At that time, the LPN got engaged in checking the condition of the patient with the respiratory distress as the Emergency Room got more patients who needed attention.

The family made a request for his removal from the life support seven days after he was admitted in the Emergency Room. Following the assessment of the step one including the timeline of occurrences leading to his death, the RCA team must identify what went wrong or which procedures were wrongly administered. The first identified was the LPN failure to inform the RN that the oxygen saturation had dropped below 85%. Furthermore, the Emergency Room physician did not make careful notes regarding the level of depressants that were in Mr. B’S body system taking into account the hydromorphone and diazepam added to his body system should not have been made for moderate sedation level. The second recommendation is proper human resource staffing in the Emergency Room to ensure each patient is offered an individualized quality care after influx of patients into the facility.

Finally, there is need to improve the Emergency Room staff knowledge on reporting of risky patient situations. B. IMPROVEMENT PLAN FOR THE PROCESSES IN EMERGENCY ROOM The RCA team should develop more effective and efficient procedures for preventing occurrence of such a situation in the ER through a plan approved by the Director of Emergency Room. The RCA team will then design a process improvement plan that includes staff-training. The improvement plan must take the three essential processes recommended in the Lewin change theory comprising of unfreezing, change and freezing also known as refreezing (Shirley, 2013). The staff in the ER should be trained on prevention of such occurrences cited in the scenario. The staff must be informed on the need for change and procedures be changed.

In this step, staff engagement and training processes are necessary (Kritsonis, 2005). In the second step, the RCA team must ensure that the recommendations are implemented appropriately taking into account all considerations. In this case, the issues the issues include increase in number of patients requiring emergency care, low staffing in the department, failure of PN to report to the RN on the drop in oxygen saturation of Mr. B, and his treatment history of taking oxycodone. Step two involves establishment of an effective multidisciplinary team to oversee the implementation of the proposed recommendations. Step three comprise of the establishment of the team goals and designing process to be followed in FMEA. The fourth steps comprises of the listing of all the potential causes and modes of failure in the Emergency Room.

1 1 3 3 Total RPN (Sum of all RPN) =863 D. INTERVENTION TESTING The testing of an intervention plan is crucial in health sector. One tool that can be used in testing the change implemented in the Emergency Room is the Plan, Do, Study, Act (PDSA) model. From this model, the protocols in the model are used in assessing effectiveness in procedure or policy changes. The first step is Plan, which is integrated in the second step Do in testing the new procedure or policy. The professional nurse must practice their services to patients through a high ethical and moral professional levels. In this particular FMEA exercise, the professional nurse plays an essential role as a change agent. The Nurse Leader in the ER plays a crucial role in identification of patient safety concerns and facilitating the team in implementation of change for better outcome.