C489 Task Two - Task 2 PDF

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C489 Organizational Systems and Quality Leadership SAT Task 2 Megan Barnes Western Governors University Jim Fischer

Updated: 12/11/20

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Organizational Systems and Quality Leadership SAT Task 2 A. Root Cause Analysis A root cause analysis (RCA) is performed to find the cause of an error or incident so that solutions can be found and used to increased quality of care for patients and to increase employee satisfaction. A team of people is generally set up to complete an RCA. A1. RCA Steps There are 6 steps in the RCA process. Step 1 is identifying and defining the problem. A complete identification should be made regarding what happened by gathering information. Step 2 is coming up with a reasonable idea of what should have happened. Step 2 is compared to Step 1 to help determine Step 3, which is determining the cause. The team should look at the factors which lead to the event. There are experts that recommend the RCA team “ask why five times” to get at an underlying or root cause (Institute of Healthcare Improvement, n.d.). Step 4 is developing a statement that links cause to effect and that to the incident or error made. A casual statement has 3 parts: the cause (“This happened…”), the effect (“…which led to something else happening…”), and the event (“…which caused this undesirable outcome”) (Institute of Healthcare Improvement, n.d.). Step 5 had the team coming up with a list of actions that would prevent the incident from happening again. Step 6 is to write a summary and share it, a flow chart can often be helpful to complete this step. A2. Causative and Contributing Factors To begin to apply the RCA steps to this scenario I would compile a team of four to six members, made up of a mix of professionals. For this scenario it would be beneficial to have the team comprised of a respiratory therapist, the medical director, the emergency department manager, and the director of nursing. It is important that the team not include anyone directly Updated: 12/11/20

3 involved in the incident. The team should determine what happened and put the information together, they should also discuss what the desired outcome should have been. The team can then compare what did happen to what should have happened to determine the causes. The sentinel event in this scenario is that Mr. B became unresponsive, then brain dead, then eventually passed away. After reviewing all the information presented, one cause identified is that Mr. B was administered a large amount of sedation medication, in a small amount of time, without consultation with the pharmacy about the effects of the medication. Mr. B was not placed on continuous blood pressure monitoring, ECG, and pulse oximeter reading throughout the procedure, as is the hospital policy. This was done after the procedure was completed. Possible insufficient knowledge regarding the medication, peak, duration, and onset contributed to Mr. B’s respiratory depression and hypotension. Another problem identified in the scenario is that Mr. B was not placed on supplemental oxygen when his saturations dropped to 85%, and the LPN did not inform the RN of this reading. Another cause identified was the lack of staff in the emergency department during Mr. B’s visit. Although a backup nurse was available, that nurse was not notified when the dispatch call came in or when the emergency department became very congested. B. Improvement Plan The first phase of an improvement plan that could be implemented is a plan regarding the use of supplemental oxygen. This could help the emergency department prevent a reoccurrence of the incident described in the scenario. I would implement mandatory education of staff on the effects of low O2 saturations on patients and the benefits of supplemental O2 use. I would then implement a new hospital wide policy for placement of supplemental O2 anytime a patients’ saturations drop below an identified level, especially if the patient has undergone sedation. The

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4 next change I would implement would be for staff to notify the RN or the charge nurse anytime saturations drop below desired levels. Implement of these changes could significantly improve patient outcomes. B1. Change Theory The three stages of change identified by Kurt Lewin are unfreezing, change and freezing. The unfreezing stage enables employees to understand why change is necessary and aids them in loosening their attachments to certain practices. In the improvement plan identified above education would be one strategy to aid with unfreezing. Education of staff can significantly improve understanding of the proposed change. The change stage includes staff starting to do things in new ways. Support during this stage is critical, so frequent communication is key. One way to aid the change stage in the proposed improvement strategy would be a checklist of what is to happen when a patients’ oxygen saturations are low. Freezing is the final stage in the change theory. This includes consistent implementation of the change by staff. A reward system, along with continued support, could aid in this stage. C. General Purpose of FMEA Failure Modes and Effects Analysis (FMEA) is a method used to identify potential failures as they appear, or as they may exist in a process. Healthcare systems use FMEA as a way to enhance quality of care and minimize damaging inaccuracies. It includes identifying parts of the process in need of change to prevent failures from occurring. The failure modes are ways the process can could potentially fail. The effects are ways the failures could lead to undesirable outcomes. C1. Steps of FMEA Process

Updated: 12/11/20

5 The beginning of a process is identifying a subject to evaluate. The FMEA should be done on a simple process. However, multiple FMEA can be done on complex processes. The second task is to gather a collaborative team to oversee the activity. Be sure to include everyone on the team that is involved in the process. In step three, the team should list all steps of the process. Step four is to complete the FMEA table. The last task would be to use the risk profile number from the table to plan improvements. This step can aid the team in considering future influences the revisions will have, C2. FMEA Table See attached table. D. Intervention Testing The PDSA cycle can be extremely useful in testing interventions for improvement. The first step is to plan. For the previously described improvement plan, this would include collecting data and putting together a new policy for supplemental oxygen use for low O2 saturation readings. The next step is to do. The staff needs to be educated on the policy, reminders need to be posted as well as the steps that need to be completed when the saturation readings alarm and are low. The third step is study. I would accomplish this by collecting data regarding how many times supplemental oxygen was utilized when saturations were low. It would also be helpful to collect data on patient outcomes when supplemental oxygen was used as well as when it was not. The final step is to act. I would do this by refining the change and making any necessary modifications effectively. E. Demonstrate Leadership The BNS RN can demonstrate leadership in promoting quality care by creation and maintenance of an open environment. Open communication between staff and the RN regarding

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6 any issues that may arise, and also the RN keeping staff informed and imparting information and education can be essential. The RN can become adept at problem solving to improve patient outcomes. They can more easily identify problems and determine which changes could be implemented for improvement. A BSN RN can influence quality improvement outcomes by being open to the process of change, keep an open mind, and understand the needs of all involved parties. E1. Involving Professional Nurse in RCA and FMEA Processes Involving a professional nurse in the RCA and FMEA process is crucial because of important qualities they possess. The main connection between patient and organization is the nurse. Nurses are able to use critical thinking and judgement to identify cause, severity, and effect of adverse events. Honesty and integrity will be used by the nurse when collecting vital information from patients, families, and coworkers. The nurse can be a positive role model to other coworkers, as well as being a mentor. The nurse will then be able to more easily identify why there may be resistance to change in her peers.

Updated: 12/11/20

7 References Institute for Healthcare Improvement. (n.d.). Patient Safety 201: Root Cause Analyses and Actions. Retrieved from https://education.ihi.org/topclass/topclass.do?CnTxT-97413168contentSetup-tc_student_id=97413168-item=1343-view=1

Updated: 12/11/20...