A Root Cause Analysis is an investigation to identify a clear understanding of a specific event and the factors that lead to the outcome. The first two steps for RCA are to identify a team for reviewing the scenario, and identification of hazards. In the case study presented, some of the causative factors were the use of conscious sedation and ignoring hospital policies. The patient was not placed on a continuous ECG monitor, and the respirations were not monitored in the recovery stage. This ignorance contributes to an error because the hospital has a policy for sedated patients. The nurse was aware of the policy but failed to adhere to it. 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. 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 sentinel event or situation does not occur again. To begin any successful change process, you must first start by understanding why the change must take place” (MindToolsVideos, 2014). In the case study, there were a few things that happened that 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.
Preparing all information to be presented to the organization can assist in building a solid foundation during the first stage of the change theory. During this period, it is crucial 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 would ensure that the staff is more accountable and therefore ensuring that the policies are adhered 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. Extra staff support and guidance should be offered to ensure that the staff is comfortable to handle the change.
Failure Modes and Effect Analysis is applied to evaluate potential failures in a 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 is to allow team members to examine the failures and determine how they could be changed. In the pre-steps for the presented case, information is gathered to determine where the conscious sedation went 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 sedation is performed. Determine the steps of performing conscious sedation. Consider the factors that could contribute to conscious sedation failing. In the case presented, step one would include setting the patient upon a monitor which checks the pulse and telemetry. Step two would be to ensure that the process is limited to the maximum amount of sedation as stipulated in the policy. Step three would be to monitor the patient after the procedure to check for the O2 saturation and heart rate.
C3. Three Steps
Step one 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, and ECG are continuously monitored. Education should be provided to staff that will be participating in the sedation process, also the ones that will be involved with caregiving post-procedure. It is also important to have break times before and after the procedure to ensure that people can brainstorm to evaluate the risks and benefits.
Nurses have a duty to act as leaders by promoting quality care and improvement initiatives. The nurse should delegate tasks such as attaching 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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