A problem solving approach that is conducted with the aim of securing the genuine reason for an event is known as Root Cause Analysis (Rooney and Heuvel, 2004). In the given case, Mr. B has an extreme pain on his left leg and hip region, and he has been taken to the doctor’s facility by his child and neighbor. Mr. B has been put through moderate sedation by a medical expert. His health and wellbeing deteriorates and he at last passes away. The purpose of this paper is to conduct a root cause analysis for Mr. B and discusses errors or hazards in care in the scenario. Change theory has been applied in the paper to develop an improvement plan to decrease the likelihood of a reoccurrence of the outcome of the scenario. A failure mode and effects analysis (FMEA) has been used to project the likelihood that the process improvement plan suggested would not fail. The last section of the paper discusses the key role that nurses would play in improving the quality of care in the situation provided.
Root Cause Analysis
Health experts in the healing center where Mr. B was taken overlooked the importance of history taking in treatment process of a patient. They failed to take sufficient medical history of Mr. B at the time of entry, and this can be identified as the first cause of deterioration of Mr. B’s wellbeing. Nurse J took inadequate medical history of Mr. B that was insufficient for distinguishing the accurate medicinal needs for execution of proper medical interventions (O’driscoll et al., 2011). The second causative factor that prompted poor health for Mr. B is failure by the doctor to build the most proper level of patient sedation. Perfect level of patient sedation could not be resolved on the grounds that the doctor did not perform a careful examination of Mr. B’s medical history.
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Unskilled staff in the health care setting is an alternate causative component that worsened Mr. B’s wellbeing (Tourtier, Diraison, and Auroy, 2011). The doctor and Nurse J could not perceive that the utilization of valium and Dilaudid to the same patient can cause unfavorable health effects to the patient. Even after the doctor had directed the nurse to administer these drugs on Mr. B, the nurse went ahead and administered the drugs, thereby affecting the patient’s health. The fourth causative variable that prompted poor patient outcome is insufficient health experts in the medicinal services setting (O’driscoll et al., 2011). Upon arrival of Mr. B’s at the hospital setting, there was only one emergency department physician, two nurses, and one secretary. This number of staff was insufficient to viably attaent to the increasing number of patients in the hospital at that time (Tourtier, Diraison, and Auroy, 2011).
This root cause analysis framework seeks to identify what caused the incident, how the incident occurred and why patient safety incidents have occurred. Root cause analysis helps a healthcare organization to identify possible areas of change, develop recommendations and look for solutions to existing problems. Basically, a root cause analysis should help prevent similar incidents from happening in future (Rooney and Heuvel, 2004).
A1. Errors or Hazards
An error refers to any form of wrong judgment over a situation while hazard is anything that is likely to cause danger. One likely hazard in Mr. B’s case is that, the nurse failed to determine the reason why Mr. B lost balance before injuring his left leg and hip. The major worry of the physician and the nurses would have been the swollen left leg and the high levels of cholesterol that could have interfered with blood circulation (O’Driscoll et al., 2011). Solving the source of the problem would have helped much in improving Mr. B’s health rather than struggling to cure the injured left leg and hip.
The second error or hazard is wrong decision made by the physician on the ideal sedation level that was to be provided for Mr. B. The doctor made a wrong judgment and preferred to relocate the left hip instead of administering some pain relieving drugs, a decision that might have affected Mr. B’s cardiovascular system, ventilation, and airway system (Tourtier, Diraison, and Auroy, 2011). Eventually, there was deterioration in Mr. B’s condition instead of health improvement.
The third error or hazard in care in the scenario is administration of double dosage of valium to Mr. B. The nurse was ordered by the doctor to give Mr. B two 5gms dose of valium at intervals of 10 minutes. This double dosage made Mr. B to experience breathing difficulties. The provision of double dosage of valium to Mr. B is identified as an error because it is seen as a wrong judgment by the physician. It is also identified as a hazard because it puts Mr. B’s life at risk (Tourtier, Diraison, and Auroy, 2011).
Nurse J failed to effectively operate the operation equipment during sedation. The nurse did not follow required protocol during the sedation process for Mr. B (Tourtier, Diraison, and Auroy, 2011). This put Mr. B’s health at risk because it interfered with his response to the sedation process.
According to change theory, a change occurs when the old systems are eliminated and replaced by new ones, and for a change to be implemented, human beings must learn to discard the old systems and be ready for the substitution (Lewin, 2013). According to Lewin (2013), change comprises of three distinct stages namely; unfreezing, moving to a new level, and refreezing. These three stages must be followed in a chronological manner before it can be concluded that a change has really occurred. By definition, unfreezing is where human beings are influenced to have a common mind towards change. Lewin (2013) emphasizes that it is easier to bring about change when every affected individual agrees with the change and accepts that a change needs to occur.
Moving to a new level, also known as Change, is effecting the real change. An idea must be made to work for an old system to be replaced successfully with an old system. The third stage known as refreezing refers to incorporation of the new routine by making it a standard working procedure. Everyone affected by the change must be made to understand that the old systems are no longer functional, and that the new system must be put into practice (Lewin, 2013).
In Mr. B’s case, the improvement plan that will assist in decreasing the likelihood of a reoccurrence of the outcome scenario involves training employees on how to handle patients, from examination of medical history to treatment administration. The health care setting also has to select and recruit additional health care professionals to take care of its ever increasing number of patients. The two changes must be executed in form of a process. The change process will follow the three steps as presented by the change theory: unfreezing, moving to a new level, and refreezing (Lewin, 2013).
First, the existing physicians, nurses and subordinate staff must be made to understand the reasons why a change is necessary in this scenario. This knowledge will make the process of change easy because all those involved will support the change (Lewin, 2013). Second, everyone in the health care setting must be allowed to take part in the recruitment and training processes. This will allow each and every one of them to give their ideas and opinions concerning the change. Eventually, the health care setting will be assisted to effect a change that will completely change its image (Lewin, 2013). Third, this health care organization must be ready to support the health care workers in applying the new skills as standard operating procedures. The physicians, nurses and subordinate staff must be taught to replace the old system with the new system by putting the change into practice (Lewin, 2013).
The members of the interdisciplinary team who will be included in the root cause analysis and failure mode and effects analysis are the hospital manager, the emergency room physician, the registered nurse (RN), the chief nursing officer, and the licensed practice nurse (LPN). All members of the disciplinary team will meet to conduct the root cause analysis and the failure mode and effects analysis in order to ensure that the proposed plan works effectively and does not fail in future. These people will be responsible for developing their own plan that will ensure that the health care setting offers effective care services to all patients (Carlson, 2012).
According to Carlson (2012), failure Mode and Effects Analysis is defined as a rational procedure used to categorize and get rid of impending reasons of failure. In the case of Mr. B, all members of the interdisciplinary team will have to take corrective actions towards the problems that have already occurred. Failure Mode and Effects Analysis will assist this health care setting to ensure that potential causes of failures or failures are reduced or completely eliminated (Carlson, 2012). Ideally, the failure mode and effects analysis will help this health care setting to project the likelihood that the recruitment and training plans suggested would succeed.
After changes in the process of care will have been implemented, it will be important to evaluate the success of interventions. Testing the success of the interventions helps in identifying whether the interventions are bringing any effective change in the process of care in the health care setting (Fuchs and Fuchs, 2006). The two proposed changes or interventions for care in this health are setting are recruiting new staff and training them to increase their competency levels. The first way through which these interventions will be tested is through analysis of the degree to which workers in the health care setting conduct their care procedures (Fuchs and Fuchs, 2006). One of the care processes that will be given much attention is the manner in which physicians take medical histories of their patients. The second way through which the interventions will be tested is through assessing how the health care professionals administer treatment. The trained health care professionals must be able to offer the right dosages and operate equipment properly in order to minimize errors (Fuchs and Fuchs, 2006).
Immediately the health care organization and all stakeholders agree that a failure mode and effects analysis is the best way to minimize process errors, members of the interdisciplinary team will have to take the following ten steps towards the implementation process (Carlson, 2012).
- Step 1: Select individual health care processes to be analyzed – Members of the interdisciplinary team must first select individual health care processes that are more important and that should be analyzed. This step will help in developing an appropriate analysis plan.
- Step 2: Define responsibilities of all team members – When all members of the interdisciplinary team are aware of their responsibilities, all tasks in the analysis process will be performed without hitches.
- Step 3: Outline the entire process in form of flow-chart – This step gives a chronological order in which tasks will be performed in the analysis process.
- Step 4: List and describe all failure modes at each and every step of the process – Listing and describing all failure modes at each and every step will help in deigning the best procedure for analysis.
- Step 5: Perform a critical assessment by determining the level of risk for each fault – This step is important because it will help members of the interdisciplinary team to understand the extent to which each and every failure or error will affect treatment processes in the hospital
- Step 6: Rank or grade the faults in matter of importance – By listing the faults in order of importance, it will be possible to identify which fault should be addressed first.
- Step 7: Design the proposed changes to reduce the risk of the highest priority failure modes – Here, the professionals who will be conducting the analysis process will use the proposed changes of training and recruitment to reduce the risks in order of priority
- Step 8: Stipulate outcome measures and test that will be used to determine success of the changes – Step seven will help in identifying the distinct methods that will be used to test the interventions in order to judge whether the effectiveness of the implemented changes.
- Step 9: Stipulate a time frame – Every task must be performed within a given timeframe. Stipulation of a time frame in this case will help those conducting the analysis to ensure that all tasks are performed and completed on time.
- Step 10: Implement the proposed changes and evaluate them. – Implementation of the proposed changes will help in ensuring that the proposed changes become a reality.
The three steps of the failure mode and effects analysis are severity, occurrence, and detection. Severity refers to the importance of a particular change effect on patients’ needs. In this case, severity defines the extent to which a given action will impact patients. Severity of failure is considered very high if the failure is likely to cause an immediate risk to patients’ safety. Basically, severity examines how serious the impacts would be should the potential risk occur (Carlson, 2012).
Occurrence refers to the rate at which a given cause occurs and creates failure modes. An occurrence is ranked as moderate when a given process has occasional failures but there are no major proportions. When failures are almost inevitable, a failure will always be considered very high. The likelihood of occurrence assesses the incidence that potential risks will occur for a given system or situation (Carlson, 2012).
Detection refers to the ability of the current control scheme to detect and prevent a given cause. The failure should be able to be noticed before it occurs. The existing controls should be able to detect the failure mode. Consistent detection controls must be known with similar processes (Carlson, 2012).
Key role of nurses
In the given care scenario, nurses have a big role to play in improving the quality of care in this situation. Nurse J should demonstrate quick concern about the case and immediately report to the medical officer present. The nurse should also inform the attending physician about the medical situation of Mr. B based on how he behaves (Hassmiller, 2010). Since Mr. B’s situation has worsened when he is already in the hospital, the nurses will help the physicians in completing a Sentinel event report. Nurse J will have to commence the completion of Variance Report Form since she identified the event occurrence of Sentinel situation of Mr. B (Hassmiller, 2010). The report will be presented by the same nurse to the supervisor present or to the Emergency Medical Officer present.
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