Root Cause Analysis is an integrated procedure that entails the determination of the underlying causes, which have led to the deviation from the normal, expected outcome in a medical procedure (Bowie, Skinner & de Wet, 2013). A deviation may ultimately result in a surprising and unwelcoming result, otherwise known as a sentinel event, similar to the one that occurred to Mr. B, in the case study above. Root Cause Analysis assists in identifying the mistakes in the system that led to the sentinel event and a future relapse prevented by rectifying these issues. For the process to be complete and effective, the events follow a chronological order. The defining characteristic in an RCA is to find a flaw in the system instead of piling blame on a single individual (Bowie, Skinner, & de Wet, 2013). This is because, in a health system, a sentinel event is mostly because of a mixture of several grave faults from almost all of the people involved.
The Institute for Healthcare Improvement (IHI) has set up a four-step layout on how a Root Cause Analysis ought to work. First, the RCA team should comprise of 3 to 5 people from various relevant health fields. This team should have at least one member representing all the phases of the administration process.
The four steps of an RCA include the following. The first step entails providing a description of what occurred. The RCA team comes up with a detailed, accurate, and chronological picture of what happened. A flowchart of the events is helpful at times. The second step involves defining what ought to have happened. The team needs to come up with a hypothetically perfect situation of what should have occurred and make a comparison to what took place in step one above. Third, we have to define the possible causes of the sentinel event. Through the use of Ishikawa or fishbone diagram, the team is to come up with loopholes in the system that lead to the sentinel event happening. These can be either hazards or error and mostly involve widespread factors such as faculty members, management, and even the patient involved. The fourth step is making casual statements. Finally, a connection between the cause and effect need to be developed by the RCA team. This involves a link between a hazard or error and the sentinel event, put down in a statement.
Root Cause Analysis of the Presented Case
A patient by the name Mr. B arrives at the rural hospital emergency department. The patient complains of pain on his left leg and around the hip region. The left leg is visibly shortened, and there is edema around the calf area with a limited range of motion and ecchymosis. The medical history shows that the patient has prostate cancer and glucose intolerance. Currently, Mr. B is under atorvastatin and oxycodone. Laboratory tests show elevated lipid and cholesterol levels. Upon evaluating the patient, the physician orders the nurse to administer diazepam, which they swiftly replaced with hydromorphone after having little effect. Sedation is finally achieved after another round of 2 mg of hydromorphone, and 5 mg of diazepam is administered to the patient. The physician then proceeds to relocate and align the hip joint appropriately.
Mr. B is in a stable condition afterward and put on a blood pressure monitor; his son is allowed in to be with him. His ECG and respirations are however not monitored. The nurse leaves to attend to other patients. The nurse then receives a distress call from the son concerning the blood pressure monitor alarm. The code team is in to stabilize the patient, a procedure that is successful after defibrillation and administration of vasopressors, reversal agents, and IV fluids. The family of the patient moves him to a tertiary hospital for advanced care where he succumbs to brain death after a week, the EEG revealed.
Steps 2 and 3
In an ideal and hypothetical situation, the following should have been done to ensure the prevention of errors and hazards. The rural hospital’s emergency room received two other patients on Mr. B’s admission and reports congestion during his brief stay. The hospital management needs expand on the number of beds available to the emergency department and the hospital in general (Bowie, Skinner, & de Wet, 2013). Concurrently, the hospital management should hire more staff as the attending staffs were overworked and fatigue played a key role in the eventual sentinel event. The fact that the same attending physician was attending to three different patients, all complaining of pain is intriguing and might have a hand in him administering an ineffective analgesic (hydromorphone) on Mr., B
An error occurs when the doctor fails to pick up the fact that Mr. B is currently under oxycodone and is obese, making sedation difficult. In an ideal situation, the physician should have picked that up earlier to prevent the use of ineffective drugs (hydromorphone and diazepam) that definitely played a role in the patient’s ultimate demise.
In an ideal circumstance, the patient should have been under supplementary oxygen during and after the procedure in anticipation of any cardiac and respiratory distress. At the same time, his ECG and respirations should have been monitored to detect any potentially fatal changes in the patient’s cardiovascular and respiration system. These were errors.
The emergency department is understaffed which led to the nurse giving less care to the patient after the procedure. She had to attend to other patients such as the one with respiratory difficulty, and more that were admitted. If the nurse had less on her hands, she would have given the patient around-the-clock care and might have anticipated critical issues earlier. Fatigue played a role too.
The attending doctor missed on critical information in the patient’s history. He was not able to detect the fact that the patient was under oxycodone. If he had, alternative and effective sedatives and analgesics would have helped. Mr. B was not under supplementary oxygen after the operation. His ECG and respirations were not monitored too. Changes were detected when his condition was already fatal.
The hospital management needs to expand the staff capacity to ensure a detailed and thorough care to the patients admitted to the hospital. An improved staff capacity will lighten the load on others, lessen fatigue in employees, increase work efficiency and ultimately lead to better patient care (Bowie, Skinner & de Wet, 2013).
The management should develop a clear and concise protocol followed by the attending staff in relation to different conditions. Such protocol would entail a set of instructions that is to be strictly adhered to with regard to different medical conditions (Bowie, Skinner & de Wet, 2013). For instance, this protocol should be availed to the concerned parties through paper prints in patient wards. This would act as a constant reminder to them to avoid future relapses. If this code is developed, some critical aspects of care such as ECG monitoring in patients like Mr. B will prevent similar sentinel events.
Local seminars and workshops, if developed, would assist employees like Dr. T to be up to date on appropriate means of conduct at work. The seminars and workshops will involve better ideas for patient care such as improved drug regimens in patient treatment and amended methods of patient resuscitation and stabilization in emergency cases.
B1. Change Theory
As described by Lewin, the three-step change theory, (unfreezing, change and refreezing), requires driving forces that will push the subject, in our case Dr. T and the hospital management, towards the desired direction. This raises the equilibrium. Relevant driving forces that raise the equilibrium include the provision of financial resources, good employee benefits, and a properly detailed blueprint to achieve the desired effect of an increased number of employees (Kaminski, 2011). As for Dr. T, driving forces include active participation in the seminars and workshops organized by management. Regarding unfreezing, the management will create awareness by communicating to employees the idea of expanding the capacity, developing the protocol and requesting them to attend local seminars and workshops. The management will ensure that the communication with all stakeholders that are involved in change is open and honest to create trust and security.
Change represents moving to a new state (Kaminski, 2011). Expanding the capacity, developing clear protocol, and attending local seminar and workshops will require a sustained effort from teams in the organization. Nurses should develop a feeling of ownership of the project’s success. The management will consider the training needs, timelines and the availability of resources.
Refreezing by turning the changes into habits involves actions such as developing regulations that ensure continuous employee recruitment and seminars. The management will continue to support nurses and all stakeholders until the change is complete.
FMEA is an instrument that helps the implementers of a service or product foresee the possible drawbacks of the service and the result afterward. The system becomes more robust and benefits all the parties involved (Ofek, et al., 2016). In this case, potential problems include little funds for employee recruitment and hosting of seminars and workshops. This potential failure will be addressed by ensuring a good financial allocation during budgeting.
C1. Members of the Interdisciplinary Team
The FMEA interdisciplinary team will consist of employees who are actively involved in the provision of healthcare. These include staff such as doctors, nurses, the hospital management, and outsiders who are familiar with health care such as health insurance providers. This team comprises of the ultimate professionals who possess the fine balance of the technical expertise required to run a health institution and healthcare giving (Ofek, Magnezi, Kurzweil, Gazit, Berkovitch & Tal, 2016). The team leader, from any of the concerned fields, is elected to give appropriate guidance. The specific individual who forms the team include,
The steps involved in the FMEA are three. The first step is preparation phase where the team comes up with potential drawbacks to the plan, for example, financial constraints. The next step is analysis, where means to stop these failures are discussed and developed (budgeting). The final step is the post-implementation period where trials are carried out to check on the affectivity of the plans made in step two above. Several steps are involved in the preparatory stage of the FMEA. The first step is revision through the construction of an appropriate flowchart detailing the elements of the FMEA as mentioned above. Afterward, step two involves the team coming up with potential aspects that may lead to failure (mismanagement and inappropriate funding). The possible resulting drawbacks of the failures are also considered for the third step. In our case, the drawbacks of the failures are patient death and an under motivated employee pool. Construction of the severity, occurrence, and detection grading system for the failures is the next step. The RPN is calculated, and an action plan developed finally.
C3. Three Steps
Application of the steps of the FMEA as discussed in the B above necessitates financial support as the main pillar. Potential flaws to this are mismanagement and insufficient funds (Ofek, et al., 2016). A blueprint followed during budgeting developed by the involved shareholders will ensure the failures do not happen. The grading of failures is with reference to hardships encountered afterward, the probability of their occurrence and the easiness of noticing them. In the above case scenario, the ranking for severity, occurrence and detection level will be between 1 and 10 whereby 1 indicates low ranking while 10 indicates high ranking. Severity encompasses the impact of failure to the patient or organization if it were to occur (Ofek, et al., 2016). A high severity correspond to a high ranking while a low severity corresponds to a low ranking.
Occurrence entails the frequency of the failure to happen. A high ranking indicates that the possibility of failure to occur is inevitable while a low ranking implies that the event is not likely to occur. Detection entails the ability to identify and prevent mismanagement and insufficient funds before it occur. A low-ranking number implies that it is easy to detect the failure. Conversely, a high-ranking means that it would not be possible to detect mismanagement and insufficient funds.
An effective method of ensuring participation in the interventions mentioned in B is using the model for improvement. The model will test participation in the seminars and workshops for Dr. T’s case. I will focus on using the Plan-Do-Study-Act cycle to test the intervention. The cycle involves the following four steps. First, I will plan for change to understand its nature. Second, I will try it and observe the results. Lastly, I will act on what is learned. The significance of testing the change is to determine the anticipated improvement and decide if attending workshops and seminars will present the desired results.
Nurses’ role as leaders in the delivery of quality healthcare entails, acting as advocates for their patients in airing out their grievances both legally and morally. An informed patient is the cornerstone of improved healthcare. Nurses have an uncanny ability to create innovations that ease access to health services (Ofek, et al., 2016). They accomplish this mainly through research work. An example of good research work developed by nurses is the exploration of the connection between nursing interventions and the results that they have on the patients (Ofek, et al., 2016). From such research work, better methods such as standardized health indicators, of assessing the quality of care provided in health institutions would be developed. Diversification of the nursing workforce and enlargement of the area of study is also effective in ensuring nurses play a significant role in the leadership of the healthcare sector.
Bowie, P., Skinner, J., & de Wet, C. (2013). Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes. BMC health services research, 13(1), 50. http://www.biomedcentral.com/1472-6963/13/50
Kaminski, J. (2011). Theory applied to informatics-Lewin’s change theory. Canadian Journal of Nursing Informatics, 6(1), 1-5.
Ofek, F., Magnezi, R., Kurzweil, Y., Gazit, I., Berkovitch, S., & Tal, O. (2016). Introducing a change in hospital policy using FMEA methodology as a tool to reduce patient hazards. Israel journal of health policy research, 5(1), 30.
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