A Root Cause Analysis Essay

Healthc be facilities that are accredited by Joint heraldic bearing are required after(prenominal)(prenominal) a sentry accompaniment to doings a root cede got epitome (RCA). A root author analysis is conducted to determine the ca enjoyment or factors that contri anded to the sentinel event. A fewer things must be asked in the RCA such as who, what, where, why and how in order to identify the cause. After the cause of the sentinel event is inflexible and a disciplinary action plan has been prepare in steer a adversity way and do analysis (FMEA) could be conducted to narrow the likelihood that it should happen again.The scenarioA 67 year old manful (Mr. B) was brought into the urgency live for pain to left branch and left hip to(predicate). The soil occurred when the unhurried had a f wholly due to him losing his balance after blithe over his dog. The hospital is a 60 live rural hospital located in Mr. Bs hometown. Mr. B was brought in by his son and neig hbor. Upon triage Mr. B was complaining of pain 10/10 on the numeric 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 star. The Patient states he had no known tot wholey(prenominal)ergies or former falls. Upon the care for assessment go for J. has noniced that the tolerant has limited post in motion, his left leg has swelling and appears shortened in equality to the right. think ab out J. has apprised the ED medico which he came to his bedside for evaluation. Upon evaluation the physician decided that Mr. B needed to have a reduction of his left hip, due to the dislocation and exit require a sensible drugging. Mr. B requires multiple doses of medicament to achieve the desired sedation affect for the reduction. in one case the reduction was successful Mr. B is left with son in the populate where a full set of vitals were non ceaselessly monitored and goe s into respiratory trial which lead to the death of Mr. B. Staffing on this day is the day of the event consisted of a secretary, emergency plane section physician (Dr. T), and two declares (one RN and one licensed practical go for). A respiratory therapist is in house and available as needed in this six bed ED and sixtybed 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 hale (BP), 88 heart rate (HR) and regular, 98.6 temperature, (T), 32 respirations (R), 175 lbs.. At 405pm- Mr. B was presumption 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 non 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 execution. The procedures concludes at 430pm. No melancholy is noted, uncomplaining is placed on monitor for blood insisting to be taken every 5 minutes along with beatnik oximeter but no supplemental group O or ECG leads (monitors cardiac rhythm method acting and respirations) was placed on patient of at this time. At 430pm- suck J allows Mr. Bs son to remain in the room with him as he is being monitor by blood pressure machine only. Nurse J leaves the room. At 435pm- Mr. B vitals are BP cx/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 get congested.LPN and Nurse J. in the parade 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 a lert Nurse J at this time. heed is not notified that patient acuity and patient load is increasing. Nurse J is now fully engaged 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 code is called and the son is taken to the waiting room.The code police squads 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 fistula rhythm with Mr. Bs B/P being 110/70. The patient is completely dependent on the ventilator, his pupils are fixed and dilated and thither is no spontaneous movements. The family as asked for the patient to be transfer red out to a tertiary installation for further advanced care.Outcome seven age later Mr. B has died. The family had orisoned that life-support be removed after brain death had been determined by EEGs. This is a sentinel event.Investigation of sentinel event should begin with a Team 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 plane section. Once the team is tramp unneurotic the RCA should be started. The team should set up interviews with all faculty that was elusive 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, mental facultying of department, and standardized work should be reviewed. When the cause is identified a nonindulgent action plan should be conducted. The disciplinary action plan go away allow a series of proje cts can be put in place to help create or change polices if needed. The new or changed polices should be put into education pathls to teach to current and new mental faculty as needed.The Root Cause depth psychologyCausative factors- (why it happened) determined causeIndividuals cause factorsNurse J did not look out procedure 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 fertilization of 85% between the 435pm-443pm. Dr. T did not take in bank bill of the patients weight and chronic pain music use. Nurse J did not question the medication that Dr. T ordered.Teams cause factors forethought was not called and informed of supplying needs and acuity of patients. hold up up staff was not called in to help when acuity and patient load had increased. Commination between Nurses and Dr. T were not present when the patient began to decompensate.Management /Organizational cause factorsUnsafe Staffing at ED. There was not passable staff present to safely manage emergencies in the ED. RCA FindingsErrors and/or Hazards1. Per converses protocol the patient was not hooked up to the proper monitoring equipment at the bedside. The facility procedure police called for continuous B/P ECG, and pulse oximetry during and after procedure until patient meet 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 pig to 85%. Oxygen was not placed on patient when O2 saturation dropped which led to respiratory failure causing the patient to code and at last led to Mr. Bs death.3. Communication b etween ED staff and management deficiencyed when staffing needs increased. Patient precaution was put at essay when the patient load and acuity increased in the ED and the staffing did not increase. Staffing shortage caused the nurse and nursing support 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 in conclusion 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 object/Change Theory/Improvement Plan1. Improved patient safety during conscious sedation in effect(p) directly all conscious sedation procedures get out be conducted per protocol. Within 10 days the conscious sedation procedure should be assessd by a committee to go through the better practices are being used. Within 30 days of this RCA allstaff should be educate on conscious sedation protocol. All 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 respect out where the miscommunication failure lies. This could be that the nursing support staff is unsuspecting of the parameters that should be reported to nurse or physician. With 10 days of this RCA a policy on documentation of communication should be put in place to plug 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 ra tio for the emergency room. Communication policy between department and management should be put in place efficient immediately to ensure that no other patient should be placed in harms 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 all(prenominal) manner. A copy of the RCA should be given to management and attractionship. Management should share 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 continue 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 return the any changes made to protocols and polices to ensure compliance and effectiveness is still in place and reevaluate the ferment to ensure patient safety.Failure mode and Effects Analysis (FMEA)A Failure Mode and Effects Analysis is proactive versus the RCA which is reactive. A FMEA assesses a turn for risks of failures or adverse effects of a process and prevents them by correcting what is wrong proactively( contribute for Heathcare Improvement, 2004). A Healthcare 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. pace one Select a process to be evaluated with FMEA. The FMEA for this paper will focus on the conscious sedation protocol. 2. shade Two advance 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 Techjot Department Tech3. Step Three Information needs to be gathered by the team. A list of flavours in the process being evaluated should be put together or even an outline of cadences would be helpful to the team. All internal and external selective information, clinical practice guidelines, current policies and procedures, current literature and any other training 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 badness outcomes, clinical practice guidelines and any research documentation that would aid in best practices for conscious seda tion.Team meetings should be structured with an agenda. A leader or primary person with extensive knowledge of the FMEA knowledge (Department of self-renunciation Patient preventative Center, 2004) 4. Step Four The Team should list the failure modes and causes. In each process all failure modes should be listed, and thus for each failure mode a list of possible causes should be listed as well. In this scenario we will use this as an examplePreparing medicationWrong medication preparedWrong dose prepared5. Step Five A Risk Priority Number (RPN) will be assigned to each failure mode for the likelihood of occurrence, for the likelihood of detection, and for the severity. This step is also known as the lead 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 importee it is very unlikely to occur and 10 inwardness 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 sextuplet The team will evaluate the results. For each failure mode the three scores are multiplied with each other. The failure mode with the amplyest 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 probable for harm it may cause. The RPN score can be as high as 1,000 and as low at 3. Example- Wrong Medication briskOccurrence- 5Detection- 6Severity- 95x6x 9= 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. rehearse 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 study. 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 phase a ll observations 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 solve a vital role in health care. Nurses have the approximately contact with a patient. Nurses carry 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 car e for each patient 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