Root Cause Analysis of what led to the Demise of Mr. B.
(Causative factors, errors, and hazards)
Hazard 1: the dog lying in Mr. B’s path so that Mr. B could not see it, leading to Mr. B’s fall
Hazard 2: Mr. B’s use of oxycodone could not permit his sedation with regular dosage of diazepam or hydromorphone
Hazard 3: Mr. B was also overweight, and this had a deleterious effect on the ability to sedate him using the regular dosages of IVP diazepam or hydromorphone.
The chief causes and errors leading to Mr. B’s death seem to have been the fact that there were two large doses of two different sedatives used on him, 2mg hydromorphone IVP and 5mg diazepam IVP, which could have affected his heart muscles, leading to a sedated-like state, which could have easily been his slipping into a coma after he could not have oxygen reaching his brain. Secondly, a non-medic being left in charge of seeing whether the monitoring machines were checking his responses was also another source of error, because the son could have easily been taken in by other aspects of the machines, and that lack of attention could have been the difference between the man’s losing his life or his life being saved.
B: Process Improvement Plan
The staffing of the facility in which Mr. B was being attended would need to be revamped with additional nurses attending to the patient at every step of the way to his recovery. In addition, at no point of the treatment of a patient should the patient be left with a non medical licensed individual. Attending nurses should be stationed at close quarters to/with patients to be reached in the shortest time possible.
Change theory
The theory of change involves adding more trained nurses to the workforce, who when evaluated meet the criteria of having met all requirements to be a nurse in the facility, An example would be, to have at leas 3-5 nurses per shift. Secondly, charts should be put at various accessible locations detailing how to deal with the sedation procedures of an overweight patient who is on atorvastatin and oxycodone, the latter a medication that might affect the sedation process. An exampled would be, placing procedure manuals in nursing stations, accessible to all nurses on shift.
C: Failure Mode and Effects Analysis
Failure mode and effect analysis is a multi step process used to identify all possible failures in a plan or design. The failure that is likely to affect the patient, and for which the analysis of the effect is concerned is the patient’s demise. By providing adequate amount of staff nurses (3-5) oversights can be prevented. There would be sufficient staff to take new oncoming patient as well as being able to monitor potentially critically ill patients more closely. Adequate nursing personnel would have allowed a nurse to closely monitor Mr. B by checking on him every 5 minutes so that the nurse would have noticed the change in Mr. B vitals immediately and acted accordingly.
The interdisciplinary team shall comprise of the superintendent, the human resources manager and senior registered nurses, made up of three or more, depending on their availability.
The interdisciplinary team with knowledge in the treatment process shall convene a meeting. The FMEA scope shall then be identified as being for better service delivery. Using flowcharts, it shall be determined that all members of this team have mustered the details of the FMEA. Functions of the scope as expected by clients shall be identified as well as how failure might occur. The gravity of each failure shall also be identified. An occurrence rating shall be determined for each possible failure, and a risk priority number shall be calculated for each. Recommended actions shall then be identified.
The professional nurse can promote quality care and influence quality improvement activities by being part of and active in a team that lobbies for appropriate nurse staffing, working in close coordination with other nursing care providers, and to closely monitor patients while also educating them on issues regarding their health and how best the nurse can be of service to them (Needleman &Hassmiller, 2009).
3. Three steps of the FMEA
FMEA is based on three steps that are Severity, Occurrence, and Detection. While describing all these steps it can be said that severity is about the intensity of bad outcome then, occurrence means the likeliness of any event or incident that will occur. Herein, detection means that how easily things can be visualized. It should be noted that each member of the staff is assigned to a numeric value to analyze the possibility of occurrence, severity, and detection. The numeric value is commonly known as the Risk Priority Number RPN and the range is 1 to 10. It quantifies the likelihood that the failure will occur. It can be said that the use of FMEA is an effective approach for the protection of the health and safety of the patients and practitioners .
4. Interventions
Individual health care of the members in the hospital is necessary, and it is the reason that the implementation of the stricter protocols is required for the conscious sedation. Therefore, it is recommended that a therapist should be there for the patients until they meet discharge criteria. Moreover, identification of the safe staffing protocols is also required in which safe nursing to the patients must be implemented. Also, the primary cause of failure that is the failure of the healthcare team members should be dealt by providing the education or training to the staff members on the possible or current issues/problems.
D: Professional Nurse Functions
A nurse can provide quality healthcare services to its patients. Therefore, it can be said a professional nurse should perform its strong role for Quality Improvement (QI) within the hospital. For that, a professional nurse as a leader should provide education about the Quality Improvement strategies. Also, professional nurse leaders are in a great position to improve operational and care processes as they can maintain patient care level by providing efficient services to the patients. The professional nursing leaders make sure that the entire nursing staff follows the hospital rules based on the Improved Quality practices. Moreover, they promote the quality care services in the hospital and focus on the identification and enhancement of the QI skills in the nursing staff.
References
Needleman, J., &Hassmiller, S. (2009). The Role Of Nurses In Improving Hospital Quality And Efficiency: Real-World Results. Retrieved fromhttp://content.healthaffairs.org/content/28/4/w625.full
Mikulak, R. J., McDermott, R., & Beauregard, M. (2008 ). The Basics of FMEA. New York: CRC Press
