JR Task 2 - C489 Task 2 Organizational Systems and Quality Leadership PDF

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C489 Task 2 Organizational Systems and Quality Leadership...

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C489 Organizational Systems and Quality Leadership SAT Task 2 JR Western Governors University Kevin Sauls

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Organizational Systems and Quality Leadership SAT Task 2 A. Root Cause Analysis The root cause analysis (RCA) is a systematic process to learn how and why errors occurred. The purpose is to look for a mistake made and then determine the cause of the incident and prevent the event from happening again (IHI, 2021). A1. RCA Steps The first step in RCA is identifying what happened and preventing it from happening in the future. This interpretation of the event must be as accurate as possible. The goal is to define what the problem is and to define its scope. Collection of data should be performed by anyone not involved in the error. The next step is to find out what should have happened. The use of a flow chart is helpful to decide on the mistake by comparing it with the correct policy or procedure. The third step is to find the cause of the mistake. This step focuses on the direct causes and the component that led to the error. Many RCAs suggest asking "Why five times" frequently to find the issue that caused the problem. The fourth step is to make a causal statement stating the cause, effect, and event that caused the outcome. It is necessary to assign accountability for implementing or changing policies to prevent future occurrences. Changes in the procedure should have measurable results to clarify the process. The fifth step is to create a list of recommended actions to prevent the recurrence of the event. It would be best if you made a schedule to evaluate the effectiveness of the policy change. The final step is creating a summary of the event and sharing it with the staff. The goal is to reduce any more errors, improve patient care, and prevent future incidents.

A2. Causative and Contributing Factors

3 There are some causatives and contributing factors that played an essential role in the death of Mr. B. The patient was over-medicated for the procedure and successfully reduced the left hip. Mr. B was put on an automated blood pressure machine and oxygen monitors. When the ED lobby became congested with incoming patients, the machine's alarm for low O2 saturation went off. The LPN resets the alarm and repeats the blood pressure reading. The first step in RCA tells us to look at and identify the problem. The LPN enters the room and resets the alarm without acknowledging the warning and not notifying the nurse. In step two, the LPN should have recognized the alarm and informed the RN regarding the alarm. The RN could have applied supplemental oxygen to the patient. In determining the cause, it is evident that the staff were overwhelmed with the influx of patients into the ED. According to the policy, the RN should have stayed with the patient by monitoring the vital signs to meet specific discharge criteria like fully awake and stable vital signs. An example of a causal statement for this scenario is that not following the policy of conscious sedation that results in the decline of the patient's health, leading to his death. A sample listing of approved actions to prevent recurrence includes developing new policies about additional staff, post sedation monitoring and revision as needed, updating or improving the software for alarms to ensure patient safety, and educating staff about communication. The final step is to write a summary and share the information with the hospital staff. By compiling the changes in policy and implementing measures, it will prevent future occurrences.

B. Improvement Plan Members of the healthcare team must implement process improvement changes to prevent future sentinel events. Members must identify the process that requires change and ensure to make appropriate changes. Staff education and training is one area that requires improvement—educating staff on the importance of silencing an alarm and notifying the RN or physician on the decrease in O2 saturation. Another area that needs improvement is medication dosing and protocols. In the scenario, the patient was given too many sedating medications. Physicians and RN's should check the patient's chart, reviewing the medical history, and refer to

4 the hospital’s protocol every time they perform a procedure. Another improvement plan that needs addressing is to improve staffing ratios. In the scenario, the ED was experiencing an influx of patient volume, and low staffing was a prominent issue. A suggestion of having on-call staff available so that more staff are available during peak times and would assume care of the patient requiring sedation. B1. Change Theory We could apply Lewin's change theory to the proposed improvement plan on Mr. B's sentinel event. The three stages in this nursing theory are unfreezing, change or movement, and refreezing. Lewin’s definition in this theory is “a dynamic balance of forces working in opposing directions” ("Lewin's Change Theory," 2020). In the scenario, the unfreezing stage informed the staff of the sentinel event, identified the problem, and encouraged all staff to understand why a change was necessary. I would implement a plan to improve education regarding conscious sedation and educate the team on the importance of the needed education and training. The next stage is the movement stage. In this stage, the goal is to inform staff of the changes, the options for the change and put it in action. I would set up specific dates and times for the mandatory training for all registered nurses and study the results from the class of their understanding to find out if another class or training is needed. The staff should utilize the new conscious sedation policy and incorporate the protocol as they perform the procedure. The last step is the refreezing stage, in which the recent change must be the proper way to do it to prevent old ways of doing things from happening again. I would evaluate all nurses who completed the training to make sure that they truly understand the policy and requirements for the sedation procedure.

C. General Purpose of FMEA

5 The purpose of failure mode and effects analysis (FMEA) is to evaluate the risk of harm and failure in the processes. The process could potentially cause failure or harm and identify the most critical areas that need developments (Improving Health and Health Care Worldwide | IHI Institute for Healthcare Improvement, n.d.). It identifies the problem in the systems, thereby preventing and reducing harmful events. C1. Steps of FMEA Process The process of FMEA consists of steps. The first step is to select a specific method to evaluate. This step is used to review procedures before they are implemented and recognize any areas that need improvement. The next step is to enlist an interdisciplinary team of people included in the discussions and personally involved in the process. The third step is to list all the steps in the process, ensuring that the team can clearly define the proposed method for members to understand. The fourth step is to input the list of actions to determine what could go wrong, why it failed, and the consequences. The last step is to use the Risk Profile Number (RPN) to design and plan improvement efforts to minimize recurrent problems. This process is essential in reducing harm and will aid in promoting patient safety. C2. FMEA Table NOTE: See attachment. D. Intervention Testing Testing the interventions from the process improvement ensures that the physician knows the patient's medical history before administering a conscious sedation procedure. A patient chart review would prove that the staff followed the checklist and utilized the new policies and procedures. This data will show to assess acceptance and development in patient outcomes. E. Demonstrate Leadership

6 A nurse can show leadership in promoting quality care by being a promoter by listening to the patient’s concerns and by adhering to the policies to promote a higher quality of care during the hospital stay. The nurse can show leadership in improving patient outcomes by being well informed and competent in using evidence-based practice to meet individual patient needs and provide the best practical care available to achieve optimal patient outcomes. The nurse can show leadership in influencing quality improvement activities by educating yourself and developing the standards of care. Quality improvement is everyone’s responsibility. Nurses are the key caregivers in hospitals that can seriously influence the quality of care provided and patient outcomes by using the nursing resources successfully.

E1. Involving Professional Nurse in RCA and FMEA Processes By involving in RCA and FMEA processes, the nurses can improve the process by having a nursing viewpoint. Nurses can provide information, offer suggestions, and provide recommendations to improve the process by looking at the failure points. As a health care professional, practical solutions to pertinent issues in patient safety will be more likely if we understand the process so that we can learn the most from adverse events.

References Failure modes and effects analysis (FMEA) tool | IHI - Institute for healthcare improvement. (2021). Improving Health and Health Care Worldwide | IHI - Institute for Healthcare

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Improvement. https://www.ihi.org/resources/Pages/Tools/FailureModesandEffects AnalysisTool.aspx (n.d.). Improving Health and Health Care Worldwide | IHI - Institute for Healthcare Improvement. https://www.ihi.org/education/ihiopenschool/Courses/Documents/ SummaryDocuments/PS%20104%20SummaryFINAL.pdf Lewin's change theory. (2020, July 19). Nursing Theory. https://nursing-theory.org/theoriesand-models/lewin-change-theory.php RCA2: Improving root cause analyses and actions to prevent harm | IHI - Institute for healthcare improvement. (2021). Improving Health and Health Care Worldwide | IHI - Institute for Healthcare Improvement. https://www.ihi.org/resources/Pages/Tools/RCA2Improving-Root-Cause-Analyses-and-Actions-to-Prevent-Harm.aspx...