Organizational Systems and Quality Leadership
Task 2
Angelica Mazanett   
Western Governors University













Organizational Systems and Quality Leadership Task 2

Root Cause Analysis

Root cause analysis (RCA) are steps to be taken in order  to identify system failure that end up  in a near miss, an error, or an actual sentinel event as it was the case of Mr. B. a 67 year old patient that was brought to the hospital with severe pain of his left hip after falling. This patient went in to cardiac arrest twenty minutes after going under conscious sedation in order to reduce his hip and die a week later after life support was removed.
There are factors that we need to review for quality improvement that led to this unfortunate and unintended event. First we look at this patient’s history which includes high cholesterol, hyperlipidemia, and IGT.  Second, the ER physician did not review pt.’s history, glucose level, weight or height before ordering medications and treatment plan. Third and most important this patient was not placed on an ECG monitor which could have alerted the staff when Mr. B. went into Vfib and also Mr. B. was not placed in oxygen via nasal cannula or NRM at bedside as is needed and mandated in a conscious sedation protocol. Something that could of  could have prevented Mr. B.’s death was also if the LPN informed nurse J that she reset the oxygen saturation alarm but did not check or assess the patient afterwards. Focusing on system causes rather than blame is the central feature of RCA.


In order to implement the change that is needed we will be using change theory:  First we will unfreeze the staff old ways, in order to increase efficiency and decreased the workload. Nurses in this department will have to follow conscious sedation protocol meaning patient needs to be in cardiac monitor, oxygen, B/P and pulse oxymeter at all times or until patients meets discharge criteria. Nurses need to assess patient on regular basis and as needed until patient is stable, which includes touching, auscultate, and talking to patient making sure pt. is comfortable and alert. Never rely on machines 100 %. We will initiate transition by collecting and analyzing this data in order to identify the problem and making this unfortunate case an opportunity for improvement. Sentinel cases need to be treated with a sense of urgency so nurses need to adapt and show less resistance or no resistance at all to this change.
We will assign a nurse director or nurse manager  as a guiding coalition that will help and empower nurses with this change making sure everyone knows what to do in case this situation arises again. Also  A vision strategy will also be developed with everyone’s help; staff can give feedback on what to do in this situation if ever arises again. Once everyone is on board with this change we need to re-freeze this process communication is number one in change theory once we implement and evaluate the change and see that it is effective, we want make sure this change becomes the new culture. New protocols,   checklists, reinforcement and guidelines will be available for staff so they do not forget the steps.
Failure mode and effect analysis is used by the healthcare system in order to prevent errors or failures anticipating what can happen and predicting the likelihood of these cases. First step to have in mind s what is going to be evaluated. In this case will be the register nurses and their processes and interventions for patients that go under conscious sedation in the emergency room.  The FMEA process will evaluate knowledge of labs tests and abnormal findings, knowledge of policies and procedures, and proper hand off report or communication between the staff taking care directly with these patients. We will assemble a team which will include members of staff or FMEA team will consist of the Emergency Room Director and physicians, Director of ED, nurse managers, respiratory therapist, lab technician or phlebotomist, radiology techs, and most important the nurses.  This team  will create a flow sheet, checklist and step by step conscious sedation sheet. Next step will be identification of potential failures, or what could possibly go wrong while patient is under sedation  and post sedation. In the case of Mr. B death communication, team dynamics and also short staff led to this patient’s critical outcome. Once we know the high risks measures, new interventions need to be written, results should be evaluated and implemented.
Safety teams continuously monitoring the staff and making sure new protocols are being follow is a must in testing the changing process. Meetings to check nurses compliance and competency level check-lists, skill knowledge and simulations of conscious sedation protocols are a must to make sure staff is compliant with new protocols. Nurses and staff should also give feedback and give suggestions to create and implement these protocols to make sure these interventions are working properly.
The importance of good preparation shows the primary steps to conducting the FMEA. All of these preparation steps must be done thoroughly for the FMEA project to be done successfully. The steps include:
1) The scope of FMEA project must be well defined and made available to all the right inputs, outputs, and interfaces.
 2) The correct team must be identified, trained, and empowered.
3) Rules and assumptions must be surfaced and agreed upon.
 4) Information must be gathered and made available to the team at all times.



FMEA uses three step criteria to assess a problem:
      1) Severity: the seriousness of the effect on the patient. This can be rated from 1-10.  One where the         patient is not affected at all  and 10 will be patient very serious injury or death. 
Occurrence: how frequently the problem is likely to occur; also 1-10 scale will be used where one is the problem is not controlled and 10 the problem is 100% controlled, and
 Detection: Rank the probability of the problem being detected easily and acted upon before it has happened, and how often is being detected.


Nurses are the most important part of the interdisciplinary team; In this case we will use their feedback and collaboration in order to influence the quality of improvement in this case. Nurses are the front line when interacting with patients, families, doctors, and the rest of the interdisciplinary team and their opinion and contributions to better patient satisfaction, quality of care  and reducing the rate of accidents or errors in the healthcare setting is key, also whom better than the nurses to let us know where and how to improve their job satisfaction.

















References
Dr. Mike Evans: An Illustrated Look at Quality Improvement in Health Care
Retrieved from: http://www.ihi.org/resources/Pages/AudioandVideo/default.aspx
Sauls, K. (November 18, 2013): Failure Modes and Effects Analysis
Retrieved from: https://d2y36twrtb17ty.cloudfront.net/sessions/34d5a158-8141-45d6-b7e7-0974a79b42eb/ae2a0697-f0fe-424f-b0cf-bea8df623e91-1d536658-4e03-4ca8-bb8d-327976fef6e5.mp4?invocationId=f5c284e7-273f-e611-9466-22000b010df0
Institute for Healthcare Improvement 2004: Failure Modes and Effects Analysis (FMEA)
Retrieved from: http://www.ihi.org/resources/pages/tools/failuremodesandeffectsanalysistool.aspx