Introduction
There are errors and hazards in care that may remain undetected for years until extraordinary events converge and expose the various weakness in the system (Rubenfeld et al., 2010, p.115). The severity of the failures has led to the death of a patient. It is therefore high time for the hospital to implement change in order to improve their system of care. In this regard, the principles of change theory will be used to help design new methods of dealing with patients from the triage phase to the discharge of the patient. The new system and new procedures will be evaluated using the Failure Modes and Effects Analysis (MindTools, 2011, p.1). But all of these cannot be initiated without first going through a Root Cause Analysis. The following is an overview of what can be done to a rural hospital badly needing organizational improvement.
Errors and Hazards in Care
Mr. B’s death was indirectly caused by an error. The hospital where he was originally treated failed to implement a moderate sedation policy to the letter. Supposedly, the system requires conscious sedation. This means that the patient is not allowed to sleep or render unconscious after sedatives are administered. Aside from that, the policy also provides a specific directive that Mr. B should be in continuous B/P, ECG, and pulse oximeter throughout the sedation process, and that this monitoring scheme should only be discontinued after the patient is fully awake and meeting specific discharge criteria.
In the case of Mr. B, the ECG monitor was never switched on. Needless to say, the ECG monitor will provide a fair warning for the nursing staff that there is something seriously wrong with the patient. It is clear that the hospital staff requires further training and that the overall system used requires improvement. Nevertheless, it has to be pointed out that blame must not be centered on the LPN even if she did nothing when the 02 saturation alarm indicated that Mr. B is not getting enough oxygen. The immediate action should have been to give supplemental oxygen to the patient. The sentinel event is the ventricular fibrillation suffered by Mr. B. This resulted in brain death seven days later. In order to apply root cause analysis there is a need to answer the question why?
Root Cause Analysis
The first level of inquiry will lead to the fact that no supplemental oxygen was given when the O2 saturation alarm indicated that the oxygen saturation was low. The reason why no supplemental oxygen was given can be understood if one will take a look at the sedation policy. It says that the patient must remain conscious all throughout the process and that there should be continuous ECG, blood pressure monitor as well as pulse oximeter but there was no mention of supplemental oxygen. Thus, the LPN was not compelled to give him supplemental oxygen and did what was expected which is to reset the alarm and monitor the blood pressure.
The second level of inquiry will reveal that the reason for the complication such as losing consciousness is the result of a significant increase in the dosage of the sedatives used. This second level of complications with regards to the case of Mr. B could only mean that there is the presence of factors that the current procedure or policy did not anticipate. For instance, Mr. B weighs 175 pounds and is taking pain killers such as atorvastatin and oxycodone. These drugs interfered with the sedative drugs that were administered to him. His elevated cholesterol and lipids may have also played a factor in the effectiveness of the sedation process, but this was not factored into the treatment process.
The mild sedation policy includes rules stating that there should be appropriate drug selection as well as acceptable dosage but in the case of Mr. B he was under intense pain and when asked concerning the level of discomfort he said that the pain level is 10 out of 10 on the numerical verbal pain scale. This is the reason why the doctor was forced to increase the dosage of the sedatives given to him.
The third level of inquiry will reveal that Nurse J could have intervened and her presence would alert her to the fact that Mr. B needed supplemental oxygen. But she was not in the room when Mr B’s blood pressure dropped precipitously. The reason for her unavailability can be traced to the sudden surge of patients needing immediate attention. If RCA was not used to determine the exact nature of the problem then it is easy to put the blame on the doctor, the RN as well as the LPN nurses. But an overview of the case revealed that some errors and hazards require immediate action and review by hospital management.
Applying Change Theory
At first, the hospital staff cannot see the need for change (Schulte, 2007, p.1). As mentioned earlier the immediate action would be to reprimand either the LPN or the RN and even the sole physician on duty that day. Hospital management may not even recognize the need for organizational improvement. Thus, the first thing that has to be done is to show the results of the RCA pointing to multiple factors that led to the sentinel event.
By doing so they will come to realize the need to look into their procedures and policies especially when it comes to the triage and administering sedatives as part of ongoing treatment. This is part of a continuous information relay until finally they are past the pre-contemplation stage and move on towards the next phase.
The second phase deals with the realization that change is needed. At this point hospital staff is ready to receive more detailed information as to the importance of upgrading the system. Then the third phase will occur and this is the preparation stage and the hospital staff will have to undergo training. The training phase will include the use of upgraded techniques when it comes to the triage and the management of ongoing treatment. The first thing that they will learn is the implementation of a new procedure when a similar situation arises.
First of all, hospital staff will be told that the moment there is a sudden increase in the number of patients, they can contact backup staff that is on-call and ready to go to the hospital at any given moment. This means that even if some of the staff are resting that day they can be called up to report to the hospital immediately and assist the overwhelmed staff. Secondly, the staff will have to undergo re-training when it comes to a new improved mild sedation policy.
In the new mild sedation policy, nurses and staff will be taught about the necessity of following correct drug usage and dosages. In this policy change there is a need to involve the doctors because ultimately, they will have to give the orders when it comes to the type of sedatives that will be used and the dosage. This also means that in the triage phase of the treatment process, the procedures involved will have to be analyzed more thoroughly. The data that will be gleaned from the triage must be processed quickly for the physician to see if there are other factors that can hinder the administration of drugs or sedatives.
The information gathered from the evaluation phase is very critical to treatment. It is therefore important to consider the use of digital technology to assure that data is not lost and transmitted to the intended recipient and for that recipient to read and understand the most pertinent details. If this is implemented then the admitting nurse will have access to a computer system during triage and then after typing all the needed information into the computer, this information can be transmitted to the physician. The layout of the computer screen can be designed so that the doctor can be alerted to critical pieces of information. In the case of Mr. B it is the information regarding his prostate cancer and the use of pain killers.
The design of the new procedures and the upgrade to the system should not proceed without first identifying the team members that will look into the problem areas of the hospital and see the big picture. If a team is only composed of nurses then the design will be limited to the skills and knowledge-base of the nurses. It is also important to include the physicians and even the administrators of the said hospital.
Failure Mode and Effects Analysis
The first failure mode identified based on the pre-work completed above is the failure to communicate effectively the data gleaned from the triage. The severity of this failure mode is high because it will determine the steps that will be prescribed by the physician when it comes to actual treatment. This means that this failure mode will have catastrophic consequences. However, by applying the changes such as the use of digital technology to record data taken by the admitting nurse, the occurrence will be low, and the detection will be high.
The occurrence of this failure mode will be low because the admitting nurse will be equipped with a computer system that will guide and enable the nurse on duty to faithfully record the pertinent information that will be transmitted to the doctors. The computer software is designed in such a way that it will not allow the admitting nurse to go to the next phase of the treatment process if questions regarding medical history and current medication are taken are not taken into consideration.
The physician on the receiving end will also help heighten the ability of the system to detect the occurrence of failure modes because the physician’s computer system will also assist him in determining if all the necessary information has been transmitted in order for him to make the correct prognosis and then the correct treatment regimen.
The second failure mode is the inability of the staff to call for help. The severity of this failure mode is not so high as to be overly concerned. This is because the degree of occurrence is also low. In rural areas the sudden influx of patients is rare. However, it is important to have this system in place. The team will have to develop a system that when a certain number of patients is about to be admitted to the hospital, the secretary will then be prompted to call the backup staff that is on-call and ready to go to the hospital at a moment’s notice.
The only challenge here is that the detection of failure is low. It is difficult to determine the right time to call for help. It is also difficult to perceive if the secretary failed to notify backup support during the time when they are needed most. Surely the administrators of the said hospital will be able to determine the lapses in judgment after reviewing the number of patients admitted versus the number of hospital staff on duty. But this realization will come too late. There is therefore a need to take a second look at this procedure and find ways to improve it.
The third failure mode is when the LPN or RN fails to follow the mild sedation policy of the hospital. The severity of this failure mode is high as demonstrated by the death of Mr. B. However, after the implementation of a much-improved sedation policy the degree of occurrence is low. This is based on the actions of the LPN and the RN in the case of Mr. B. These nurses demonstrated that they can follow rules. Therefore, no one was at fault because they were simply following instructions to the letter. The only problem is that the said sedation policy failed to anticipate cases wherein the patients are taking pain killers and therefore requiring the need for a higher dosage and thus it was impossible to maintain consciousness all throughout the treatment process. In this regard, a much-improved policy will provide new guidelines when nurses encounter problems like that. One way of improving the treatment process is continuous monitoring of the patient until he or she regains full consciousness. If the nurse will have to leave the room, then monitoring equipment must be used to monitor heart rate, blood pressure, O2 saturation, ECG, etc.
Role of Nurses
Nurses will play a key role in improving the quality of care and ensure that the death of Mr. B will not happen again. Nurses play a key role in all the aspects of treatment starting from the time that patients are admitted to the hospital, when they are evaluated during triage, and when it is time to give them the treatment that they need. There is no other personnel in a hospital that has an overarching view of the whole treatment process. The nurses can see a significant portion of the whole operation as compared to the physicians and the administrators. More importantly, they spend a great deal of time interacting with the patients. It is imperative to make them a part of the team that will handle the planning and development of new procedures and policies to implement organizational change.
Conclusion
The death of Mr. B was just unfortunate because the problem could have been addressed before it occurred. However, hazards and errors are almost undetectable until something extraordinary happens in a medical setting. In this case, it is the overcrowded hospital and the overwhelmed nursing staff with their hands full. It is also the existence of a patient who had multiple health problems a dislocated hip and at the same time getting treated for prostate cancer. These factors came together to expose the weakness of the system such as the insufficient way of gathering information and transmitting the same. The weakness in the sedation policy was also revealed and corrected. The hospital must consider the use of digital technology to improve the way they deal with their patients. However, the principles of change theory will give them a fair warning that these things are easier said than done.
References
MindTools, 2011. Failure Modes and Effects Analysis.Web.
Rubenfeld, et al., 2010. Critical Thinking for Nurses: Achieving the IOM Competence. MA: Jones and Bartlett Publishers.
Schulte, S., 2007. Avoiding Culture Shock: Using Behavior Change Theory to Implement Quality Improvement Programs. Web.