RCA and FMEA Sceanrio

Singling out a single factor helps the team in coming up with an expedient resolution to the problem. Therefore, in conducting an RCA, rather than dealing with the symptoms, the exact underlying issues are resolved. A Root Cause Analysis therefore focuses on analyzing events and problems in order to establish “what happened, the exact way that it happened and the reason why it happened, thereby laying down a foundation of what actions should be taken to prevent the occurrence of a similar situation (IHI, 2017). A1. RCA Steps The first step is identification of what happened. These recommendations are basically changes that can help to prevent the error being reviewed from occurring at another given time in future. The sixth and the final step involves a summary of the collected information which is then shared with the key-players.

This summary acts as a starting point for the next actions that should be taken to improve the situation (IHI, 2017). A2. Causative and Contributing Factors The scenario in this case involves a 67-years old patient who died as a result of brain death. Five minutes later 2mg hydromorphone were administered to the patient and still Mr. T was not satisfied with the patient’s sedation response. Nurse J was then ordered to administer the patient with another 5mg diazepam and 2mg hydromorphone. It is important to note that both drugs have sedation effects where diazepam was supposed to act as a muscle relaxant and hydromorphone as a pain reliever. It’s after administration of the above drugs when Mr. The code team comes to the room to revive the patient, who is now in ventricular fibrillation, but after CPR, intubation, defibrillation ad administration of effective medication (reversal agents, vasopressors and IV fluids), his ECG, BP and pulse goes back to normal.

The patient is however unable to breath independently and no spontaneous movements are detectable. This is when he is transferred to a tertiary medical facility for advanced care. Under ideal conditions, this incident could have been avoided if certain procedures were followed by the ED. For instance, the doctor should have carefully reviewed the patient’s medical report carefully before ordering the nurse to administer high doses of at diazepam and hydromorphone short intervals. T immediately. This however did not happen and the LPN just chose to reset the alarm on the oxygen saturation monitor and left. The most apparent cause of this event is the fact that Mr. T failed to carefully review the patient’s medical history and therefore was not able to realize on time that Mr.

B was already used to opioids. B. Improvement Plan The most important intervention that would be effective in reducing the occurrence of a similar would be to ensure that all medical personnel learn and understand the moderate sedation/analgesia policy. It is disturbing to note that the medical team in this scenario failed to take the policy into consideration while performing “conscious sedation” and hence the unfortunate occurrence happened. This policy requires that a patient stay on continuous pulse oximeter, BP and ECG throughout the procedure, until certain discharge criteria is met. Moreover, it is required that such aa patient be closely monitored by a nursing personnel which was not the case in this case scenario. B1. Change Theory Change is a real phenomenon.

In 1951 Kurt Lewin a social scientist introduced a 3-step change model. The first step of the change theory is “unfreeze” the status quo/existing situation. Most people do not like change and therefore the purpose of unfreezing is to overcome group conformity and individual resistance (Kritsonis, 2005). This can be achieved by having the nursing team as well as the physician understand that the event that occurred was not only hurtful to the hospital but also to the patient. It’s the responsibility of the medical team to therefore attend educative sessions which will not only teach them on how to handle patients effectively for better outcomes but also on how to effectively follow the hospital’s policies. However, rather than having them feel guilty about the incident, it would be much helpful to encourage them to look at the problem from a new perspective; as a starting point for improvement.

In addition, laying out resources for the teaching sessions and policy establishment is critical. The third step is “refreezing”. When using FMEA, recommendations are that simple processes be evaluated, rather than complex processes. The second step is recruitment of a multidisciplinary to ensure that all involved persons are included in the process. This is important because different people have different job specifications and therefore each person understands best what they do. The third step involves bringing together all involved persons and listing the process in the most specific way possible. This is a step that may take a considerable length of time depending on the complexity of the process being evaluated. The seventh and the last step involves utilization of the obtained RPNs to determine areas of the process that need improvement (“Institute for Quality Healthcare Improvement,” 2014).

C2. FMEA Table Steps in the Improvement Plan Process Failure Mode Likelihood of Occurrence (1–10) Likelihood of Detection (1–10) Severity (1–10) Risk Priority Number (RPN) 1. Review of “conscious sedation” policy Some may fail to understand the policy 9 5 3 135 2. Sufficient staffing Several staff members may call in sick 1 6 2 12 3. Then after the changes have been implemented observations would be made, and data collected on the improvements associated with each intervention. This data would then be analyzed and compared with the expected results and this would provide information of what modifications need to be made thereby improving care. E. Leadership Demonstration Any given organization functions effectively when there is effective leadership and healthcare is no exception. Great leadership skills are highly beneficial for patients’ care. The care that a patient receives is directly associated with the final outcome (Cherry & Jacob, 2014).