RCA and FMEA Task 2 - Grade: B PDF

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1 Organizational Systems Task 2

Natalie Wright Organizational Systems and Quality Leadership Task 2 Western Governor’s University January 8, 2021

2 Organizational Systems Task 2

Root Case Analysis and Failure Modes and Effect Analysis

The general purpose of conducting a root cause analysis is to identify the underlying problem or “cause” of an event that has taken place. To find the cause is to possibly prevent it in the future, and to also put policies in place with the goal to keep an unwanted event from happening again in the future. As quoted by an article root cause analysis is defined by “a process designed for use in investigating and categorizing the root causes of events with safety, health, environmental, quality, reliability and production impacts.” (Rooney, 2004). There are six steps used to conduct an RCA, as defined by IHI. Step one is to ‘identify what happened’. This can be done by a team coming together and carefully go over the event trying to miss no details. Step two is to ‘determine what should have happened’; in the same group discussion should be made over what could have happened if certain things were put into place, or if one would have acted differently. Step three is to ‘determine the causes’; the team can than look at what the underlying issues were that lead to the event. Such as insufficient staffing, communication, stress, etc. Step four is to ‘develop causal statements’; these causal statements will show how certain causes lead to the poor outcome. Per IHI the “causal statement has three parts: the cause, the effect, and the event”. Step five is to ‘generate a list of recommended actions to prevent the recurrence of the event’; these suggestions will be put forward by the RCA team. In the case of Mr. B; the RCA team should include all staff working the emergency department during the event. Step six is to ‘write a summary and share it’; this would before the goal to decrease this event from happening again in the future. In applying the root cause analysis process to the scenario; it appears that there were several causative and contributing factors that led to the event outcome. The first is that the patient should have been put on an ECG during and after the procedure. The second is that the MD and nurse could

3 Organizational Systems Task 2 have waited a little longer before giving the second round of medications, and the narcotic and benzodiazepine should not have been given at the same time. If they were staggered it is possible that they would have had an effective amount of sedation. The risk is high because both medications can cause respiratory depression. The third contributing factor is that the RN or LPN should have been going into the room every 5 to 10 minutes to check the BP and 02 saturation readings. The last contributing factor is when the LPN checked in on the patient when the 02 saturation was 85%, they should have requested oxygen, and called for RN and the rapid response team. There are several improvement plans that could decrease the likelihood of reoccurrence of this event. One of the improvement plans is that the organization or unit could implement a “double check; check list”. Where the nurse would have to go through this check list of ensuring that the oximeter, blood pressure cuff, and ECG are in place prior to starting the procedure. Another plan could be is to standardize the way that the providers perform sedation; such as using the same drugs (unless there are allergies) and concentrations, and when to increase concentrations i.e. a narcotic formula or weight based dosing that the entire team is trained on and aware of. Finally, one of the most important issues/causes that was found was a possible “buddy system” where if the nurse in the procedure is called away for an emergency, then another licensed colleague whether it be the LPN or the RT available can step in to monitor the patient until they are stable. Lewin’s change theory on the human side of change is defined by “unfreezing” by getting the team together and creating a dialogue between the team and “brain storming”. Then a process of change. This change is in someway changing the behavior or thoughts that the “old way is better than the new”. The third phase is “refreezing”; in establishing a new process or technique and making it the “policy”. This should be given support and rewards to encourage a positive outlook on the change (Kaminski, 2011). A new plan in using this technique could be started by having a meeting between the staff working that day so they could problem solve what could be done differently in the future. Such as

4 Organizational Systems Task 2 implementing a new “double check; check list”. This should be met with encouragement, and optimism. They could then test out the new idea within their unit, and if it shows success; “refreeze” the new process and make it policy. Failure Modes and Effects Analysis is a tool that is used to retrieve data and analyze a policy or process in which harm could occur. As defined by IHI the FMEA tool has teams go over, evaluate and gather information for the following; steps in the process, failure modes (what could go wrong?), failure causes (why would the failure happen?), and failure effects (what would be the consequences of each failure?). In the FMEA tool that is attached there were several improvement plans listed. One for example is “when assisting in “moderate sedation”, nursing must perform and chart the “double check; check list”. Checking off that the oximeter, BP cuff and ECG is in place on the patient. This process would be at a low risk of failure because it could be a hard stop in the charting. Being that nursing could not move forward with the action until the check list is completed; see attached for more information. To implement and test the improvement plan; first, one would need to create the check list needed. Then let staff go over it and let them give feedback for possible change. After this submit it to the charting system to be integrated (EPIC for example), and then make it a “hard stop” so that nursing could not move forward until the check list was completed. This could be implemented first in the Emergency Department. The nursing supervisor, and quality improvement team could monitor the success by pulling up documentation of vital signs from “moderate sedation” procedures over the last year and compare with vital signs from “moderate sedation” procedures over the next quarter. Nursing can demonstrate leadership in the following areas. Nurses can promote quality care by taking time with their patients and advocating for help when they are overwhelmed. Also, it is important for nurses to speak up when physicians may not be appropriately dosing medications, CNAs are providing inadequate care or not reporting issues. When nurses advocate and promote quality care it will improve patient outcomes. In the scenario with Mr. B it is likely that the outcome was

5 Organizational Systems Task 2 preventable, and he could have had a much better outcome. This would have been dependent on the nurse advocating for themselves and the patient by asking for help, and questioning/asking for reasoning of the MDs choices for medication dose and timing. A nurse can easily influence quality improvement activities by joining a QAPI (quality assurance project improvement) team. Most hospitals and units have them, and they encourage anyone from CNA, housekeeping, physician, and RN to join. A professional nurse that involves themselves in the RCA (root cause analysis) and FMEA (failure modes and effect analysis) can have a strong influence in how things may change on their unit and demonstrates how they can be a leader to their colleagues. Not only can they, but one might argue that it is important. A nurse gives an outlook and perspective that an MD, CNA, and manager does not have, and being a part of a quality improvement team could be very beneficial for any organization and unit.

References: Rooney JJ, Vanden Heuvel LN. Root cause analysis for beginners. Qual Process . 2004 July; [Accessed on January 5, 2008]; Available at: www.asq.org. Institute for Healthcare Improvement: Patient Safety 104: Root Cause and Systems Analysis Summary Sheet Kaminski, J. (2011). Theory applied to informatics – Lewin’s Change Theory [Editorial]. Canadian Journal of Nursing Informatics, 6(1). Retrieved from http://cjni.net/journal/?p=1210...