A Root Cause Analysis is a systematic procedure for identifying and evaluating the causative factors of events or problems and a method for responding to them to ensure that they do not happen again. The initial two steps for RCA are to select a team for reviewing the specific situation and, and identification of hazards. In the case study presented, the root causes of the problem were incorrect monitoring of conscious sedation, as well as ignoring hospital policies. The ECG procedure of the patient, in this case, was not continuously monitored, and during the recovery phase, his respiration system was not regularly monitored. This ignorance contributed to an error since the hospital had a conscious sedation policy that the nurse-in-charge failed to adhere to. Though the nurse was aware of the policy, she failed to properly take the contents in to consideration, thus leading to a fatal incident. Another mistake that might have occurred in this case was when the LPN was unable to administer supplemental oxygen to the 02 saturation that was at 85%. The right thing for the LPN to do would be to stay in the room with the patient to monitor his heart rate and respiration. The patient who came in with respiratory distress is an example of a hazard. The reason for this is because he distracted the nurse’s attention from her current duties and she had to attend to him. In this situation, the nurse would have called in additional staff to help with the incoming patient so that could focus on the patient already in the ER.
Establishing an improvement plan helps to ensure that the medical error or situation does not occur again. Before starting the change process that will produce positive outcomes, hospital management must first understand the importance of the change taking place (MindToolsVideos, 2014). In the case study, there were a few events that happened which highlight why change is needed in the ER. The nurse did not follow the hospital policy regarding conscious sedation. An improvement plan would be to recommend continuous monitoring of patients by nurses or tech staff following conscious sedation. A plan like this will help reduce the risk of overlooking things. Another improvement plan would be to decrease the workload on ER nurses by adding more staff to assist in patient care.
First of all, it is essential to adequately prepare all data and information to be presented to the organization. It is a crucial step because it helps in building a firm foundation during the first stage of the change theory. During this period, it is vital that the current policies and procedures are not made to appear ineffective. Only facts should be stated. Ensuring that proper communication is maintained during the change process will help make the employees aware of what is expected of them. Participative or democratic style of management would be ideal when gathering ideas and information to help with the change (Cherry and Jacob, 2014). In the second stage of change theory, it would be recommended that the ER staff review and understand current policies and be allowed to give their inputs on additional care for conscious sedation. This step is critical because it would ensure that the staff is more accountable and therefore ensuring that the policies followed to the latter. It would also be essential to have a leader to help the team with any questions during the process. Stage three would require constant monitoring to determine whether the change has been adopted. Staff evaluation in regards to compliance with the change policy and new rules will need to be put in place. The staff members in charge of the process should be provided with extra support and guidance to ensure that they are comfortable to handle the change.
Failure Modes and Effect Analysis (FMEA) is applied when aiming to evaluate potential failures in an event or process and the possible causes for the failure. The method determines what might fail; when it fails; and how to ensure that this does not happen. The questions to ask are ‘what might fail in the process?’ And ‘How do we prevent this to ensure positive outcomes? The first step to this analysis is allowing team members to examine the errors that occurred and determine how events could be changed to avoid a repeat. For the presented case, the first step would be ensuring that accurate information is gathered to determine where the conscious sedation started going wrong. The three steps are then used to determine the severity of the failure, rate of occurrence of this type of failure, and how to mitigate such failures in the future. The last step is implementing the change and monitoring progress for every process.
C1. The Interdisciplinary Team
The interdisciplinary team would consist of the ER director, ER charge nurse, the LPN/RN, risk manager, and tech.
Gather information and statistics about how often conscious sedation is carried out. Focus on the step-by-step review regarding the application of conscious sedation. Determine the factors that could contribute to conscious sedation failing. In the case presented, step one would include setting the patient upon a monitor that reviews the pulse and telemetry. The second step would be to ensure that the process adheres to the maximum amount of sedation as stipulated in the hospital policy. The third step would involve monitoring the patient immediately and at regular intervals after the procedure to check for the O2 saturation and heart rate.
C3. Three Steps
The first step is likely to fail if there are several patients and only one nurse in the ER. To counter this mistake from happening, it is critical to ensure that when one RN is overwhelmed in the ER, extra staff should check in to assist. If no additional RNs are available, the moderate sedation should be postponed. Not adhering to this step might lead to failure in all the other preceding steps.
Step two could fail if the patient fails to respond to medication at first and the doctors go ahead to perform the procedure. It is essential to know the policy and be aware of the amount of medication to be given.
Step three may fail if no one was available to monitor the patient and to respond to alarms. If not checked, this could result in death.
Interventions for the improvement plan would involve being able to monitor incidents of conscious sedation. The multidisciplinary team will have to evaluate the policy concerning this matter and whether it is adhered to. It is also vital to ensure that a patient’s B/P, O2 saturation, andECGare continuously monitored. Education should be provided to staff members who will be performing the sedation, as well as the ones who will be involved with care-giving post-procedure. It is also essential to have break times before and after the procedure to ensure that people can brainstorm to evaluate the potential risks as well as the benefits.
Nurses must first take the leadership role in ensuring that patients receive quality care. They should also be concerned in evidence-based practices to develop a measure for improvement of healthcare services for patients. The nurse is also responsible for delegation of tasks such as placing patients on the ECG monitor, charting and documenting vital signs, and monitoring the patient and the alarms. Delegating ensures that everyone is assigned a specific job and that no step is skipped in the process. The nurse should also raise concerns in cases where the procedure instructions are not being followed and ask for assistance when overwhelmed. Patient safety and quality care is a priority in the medical field, and this is made possible by providing quality care and services to patients.
Cherry, B., & Jacob, S. (2014). Contemporary Nursing: Issues, Treands, & Management (6 ed.). St. Louis: Elsevier Mosby.
MindToolsVideos (Director). (2014). Lewin’s Change Management Model: Kurt Lewin’s Unfreeze-Change-Refreeze Theory [Motion Picture]. Retrieved from Mind Tools: https://www.mindtools.com/pages/article/newPPM_94.htm
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