Root Cause Analysis
Root cause analysis (RCA) is a process in which the healthcare providers retrospectively study the past events with adverse outcomes for patients’ health (“Patient safety essentials toolkit,” n.d.). It is done to determine the root cause of these events to prevent them from happening again in the future medical care. The importance of this analysis should not be underestimated, as critical analysis is essential for achieving better patient outcomes.
Root Cause Analysis Process
Institute for Healthcare Improvement (IHI) describes six steps to conduct an RCA (“Patient safety essentials toolkit,” n.d.):
- Identify what events.
- Determine what should have happened instead.
- Recognize the causes.
- Create casual statements.
- Think how to avoid reoccurrence of the events.
- Make a summary of the analysis.
These six steps allow the medical staff to recognize the issues that caused the negative outcome and find a path to avoid repeating the mistakes in the future.
Root Cause Analysis Application to the Scenario
According to the Root Cause Analysis, firstly the event should be defined – Mr. B was admitted to an ED due to severe pain in his leg and hip area. Then, the clauses should be clarified – he had fallen, tripping over the dog. The patient was admitted by Nurse J and Dr. T in case of finding the possible solutions, and he ordered the administration of sedative to process with manual hip manipulation. The actions were taken and then after verifying the solution ineffectiveness, more sedative was administrated when the first dosage did not work. According to the analysis, it should be started from the beginning in case of repeated attempt to figure out the root cause and another solution. After a short period, Mr. B’s son alerted them of alarming vitals. The patient did not respond to stimuli, and no palpable pulse could be detected. Mr. B was transported to a tertiary facility for advanced care, where seven days after EEG determined brain death and Mr. B was taken off life support.
Process Improvement Plan
The medical staff should be trained to keep an eye on patients under heavy sedation and supply them with oxygen, especially when the hospital does not experience a staff shortage. Medical staff should check the blood pressure, oxygen, and other vitals regularly, and the sedation should be administrated with more care. Additional or repeated sedation training modules might be necessary for the staff.
Lewin’s Change Theory
The first stage of Lewin’s change theory is known as unfreezing: in this scenario, additional training for the personnel, using similar examples, would be needed to change the way they view similar situations (“Lewin’s change theory,” 2020). The second stage, change, would require the hospitals to implement more strict regulations regarding sedation of patients and the care during the recovery. Finally, the refreezing stage would mean establishing the new process as the norm for the staff.
Failure Mode and Effects Analysis
Failure Modes and Effects Analysis (FMEA) is utilized to evaluate a process and see where it may fail and lead to negative patient outcomes or harm (“Failure modes and effects analysis (FMEA) tool,” n.d.). Each part of the process is analyzed, and potential issues are identified. It helps to foresee any potential positive or negative consequences of a process.
Failure Mode and Effects Analysis Steps
The first step assumes the outlining and the establishment of the incident, collecting the needed information. The second step – structure analysis, here is supposed to simplify the understanding of the process, identify the central element of the extension and illustrate all aspects related to it. The third step consists of functional analysis, the matching between the acts and the requirements. The fourth step considers the failure analysis, and it is related to the structure and functional analysis to resolve the potential causes. The fifth step estimates the risk analysis from which each or several collapses’ severity, occurrence, and detection are evaluated. The sixth and seventh steps are connected with developing the following actions, which aim to remove the future failure causes, improve the control system, and document the results of the FMEA analysis.
Process Improvement Plan Interventions
It would ensure that staff are given necessary supplemental oxygen if necessary, and keep them supervised by either me or other trained medical staff. Doing that would ensure the best possible care for patients under sedation, and avoid negative outcomes. The inspected issue, with Mr. B, should include in its FMEA report such effects as improper dosing, improper use of substantive drugs. The actions to reduce failure mode can consist of the required tool with more widen information and possible dosing for nurses, imposition of CPOE system, selection criteria, according to the scale of priority of permanent patient observing till stabilization.
Leadership in Professional Nursing
A professional nurse can promote quality care by ensuring that the patients are listened to, supervised, and treated with close attention to their symptoms. They can improve patient outcomes through team building, so each team member follows their task and responsibilities to the best of their abilities. A leading nurse should have direct involvement in quality improvement activities and lead by example and listen to the team to ensure that their opinions are taken into consideration during these activities.
RCA and FMEA Processes in Leadership
Professional nurses can improve their leadership, personal, and medical skills when applying RCA and FMEA to their work. It helps them see and acknowledge any weaknesses, issues, and loopholes that could negatively impact their work. Using these tools demonstrates an interest in self-improvement and self-analysis, which is essential for a team leader and could be further applied to the practical implementations of their leadership and nursing skills.
References
Failure modes and effects analysis (FMEA) tool. (n.d.). Improving Health and Health Care Worldwide | IHI – Institute for Healthcare Improvement.
Lewin’s change theory. (2020). Nursing Theory.
Patient safety essentials toolkit.(n.d.). Improving Health and Health Care Worldwide | IHI – Institute for Healthcare Improvement.