Root cause analysis
The healthcare system recognizes its first priority as the safety of the patient and the ability to afford the patient groups quality care. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has an obligation to ensure that healthcare facilities live to this expectation and one of the methods that have been employed over time to oversee the sustenance of quality and safe care is the requirement that all healthcare facilities regularly conduct root cause analysis of their facility (Chen, Schein & Miller, 2015). The RCA process is based on the need to determine any existing misses and errors that may predispose the patient population to harm and therefore designing responses that can avert possible dangers. The process is carried out as an internal obligation of the facility by recognizing the errors that have occurred in the recent past and those that led to adverse effects or near-death experiences of the patient and subsequently developing measures to prevent such occurs on the future.
In the case of MR. B, the RCA team could have included the RN, the Emergency Department supervisor or manager, the LPN, Mr. B’s physician, the Chief Nursing Officer and a representative of the executive arm of the facility. Some of the issues that led to the brain death of Mr. B, either directly or otherwise included the lack of ECG monitoring as required by the protocol within the facility that all patients under sedation be under ECG monitoring. This could be translated as ignorance or intentional errors. On the other hand, the patient was not placed under supplemental oxygen. The LPN had at some point responded to the O2 saturation alarm and while it was indicating a low saturation level, the LPN decided to rest/stop the alarm without any further action on the low saturation as indicated. The second response after the O2 alarm had sounded a warning was to call for the STAT CODE. The lack of communication between the LPN and the other members of the care team specifically the RN is an indication of a lacking reporting system. The STAT CODE could have been avoided had the LPN informed the RN on the first instance that the saturation levels were below normal levels. The LPN was handling a situation for which they had not been certified to manage as required by the facility’s policy for the completion of the moderate sedation module for all care givers managing sedation cases.
Further, the continuous administration of the hydromorphone and diazepam dosages is a further indication of the inexperience and non-adherence to policy within this facility. The facility’s policy requires that any administration of these medications be based on factors of age and weight which were not considered in this particular case. The staffing levels and the staff mix at the facility were far from the standard staffing levels even at a time the patient volume and the acuity of care required was higher than normal.
The change theory
The RCA process is never complete until the errors and misses that have been indentified are resolved to prevent similar occurrences in the future. The change process has to be systematic and this implies the use of a standard framework. The Lewin’s change model will be utilized in this case. The Model has three phases; the unfreezing, the transition and the refreezing phases. In the unfreezing phase the idea is to involve the staff and the stakeholders at this facility and collect their perspective on the existing policies, staffing ratios and the staff mix as well as whether they think that there is need for improvement and the strategies that they could prefer (van den Heuvel, Demerouti, Bakker & Schaufeli, 2013). This phase ensures that the ultimate decisions and changes are supported by the majority and there is minimal resistance. In the second phase, the transition phase, the data and evidence collected from clinical data and the views of the staff will then be used to develop a staffing grid and scheduling system that will accommodate the patient volumes and their change over time. The results of the grid will then be implemented systematically as dictated by the financial factors and resource availability. In the last phase, the unfreezing phase, the implemented change will be monitored and evaluated over the course of time to determine whether it is impacting positively on the patient outcomes. Once this is ascertained, the changes will be indicated as policy within the facility (van den Heuvel, Demerouti, Bakker & Schaufeli, 2013).
Failure Mode Effect Analysis
Once a change has occurred, there is need to extend the monitoring further to ascertain the changes of failure of the processes that have been initiated. The Failure Mode Effect Analysis is the process that is utilized in such cases and this is accomplished by the members of the RCA team. In this case, the FMEA team will also include the respiratory therapy manager and physicians based in the emergency department who were initially not in the RCA team.
The pre-steps of the FMEA
The formation of the team for the FMEA is the initial step on which the actual solution can be designed in a tailored mechanism. Once the team has been formed, the next process if the selection of the process to analyze. In this case, the process to analyze is based on the problem or safety event that has been identified, in this case, the Emergency Department. This is then followed by the selection of a team facilitator who is usually appointed by the leadership to act as an educator for the team members the team members are only those who are directly affected by the process in this case, those working within the ED unit. The facility them acquaints with the members and the process is described so that everyone has grasp of the expectations. In the fourth phase of the pre-steps, the team members will discuss the challenges that may be encountered in each of the three steps of the FMEA. Once these are identified, in the fifth step, the team members will pick among the identified problems which should be afforded greater focus or priority. In the sixth step of the pre-steps, the team members will allocate or delegate roles and develop channels of communication to facilitate the development of an agreeable and diverse solution (Chen, Schein & Miller, 2015).
Severity: The ED is the area of concern with three major issues to be addressed. There will be a need for increased staffing levels, with a proposal of achieving at least a nurse-patient ratio of 1: 2 and a diverse staffing mix. In recognition of the financial limitations that may hinder the hiring process, the proposal is to have resource nurses who can supplement the ED nurses during sessions of high patient volume and high acuity of patient needs. Thirdly, the need to have the nurses in the ED undergoing the moderate sedation module as early as in the first three months of practice at the facility will be adopted as a policy on instant (Liu, Liu & Liu, 2013).
Occurrence: The resource nurses will have to demonstrate their experience in critical care nursing as well as certification on the same. The proposal is to acquire nurses with at least two years of experience in critical care nursing environments (Chen, Schein & Miller, 2015).
Detection: The grid will be used to determine the changes in patient volumes and therefore standardize the process of calling in the resource nurses.
Testing and evaluation
The Plan, Do, Study, Act (PSDA) method has been chosen as the evaluation strategy. The PSDA has four phases; in the plan phase, the idea is to design and implement a system that will help in collection of relevant data that can be used to determine the improvement or otherwise of patient outcomes. In the Do phase, the data on all cases of sedation within the ED for the next six months will be collected. Similarly, the cases of sedation handled in the ED for the last six months will be analyzed as the baseline data. In the study phase, the baseline data will be compared against the data for the six-month post-implementation of the changes at the facility and this will be used to draw patterns and trends. In the Act phase, the results of the study phase will be used to develop any responses to improve or modify the system within the facility (Chen, Schein & Miller, 2015).
Role of the Nurse as a leader
In the current healthcare environment, the nurse is regarded as the patient advocate. In this role, the nurse has to recognize that their actions of good will may be hindered by the inaction at the administrative and management levels. In this case, the nurse has to employ their political skills to help negotiate with the members of the administrative level the need for change and their impact on the patient outcomes. Nurses are the caregivers and their interaction with the patient means that they understand the technical impediments to their roles and how they can be resolved. This can only be achieved, if the nurse stands out and recognizes the various issues that may lead to adverse effects and outcomes even before the RCA teams within the facility identify them. While decision making is usually at the top by the administrative leaders, the nurses should ensure that they are the source of those ideas that influence change by keeping the communication channels active (Chen, Schein & Miller, 2015).
References
Chen, T. C., Schein, O. D., & Miller, J. W. (2015). Sentinel events, serious reportable events, and root cause analysis. JAMA ophthalmology, 133(6), 631-632.
Liu, H. C., Liu, L., & Liu, N. (2013). Risk evaluation approaches in failure mode and effects analysis: A literature review. Expert systems with applications, 40(2), 828-838.
van den Heuvel, M., Demerouti, E., Bakker, A. B., & Schaufeli, W. B. (2013). Adapting to change: The value of change information and meaning-making.Journal of Vocational Behavior, 83(1), 11-21.
