RCA and FEMA Task 2 Sample Paper
ROOT CAUSE ANALYSIS
The Institute for Healthcare Improvement defines a Root Cause Analysis (RCA) as “a process widely used by health professionals to learn how and why errors occur” (Institute for Health Improvement, 2018). A Root Cause Analysis facilitates understanding exactly what happened to cause a sentinel or an adverse event and how to design a plan to keep it from occurring again. The RCA is conducted by a multidisciplinary team in order to have a broad range of knowledge available during the process. The Root Cause Analysis is a proven evidence-based method.
There are six steps involved in conducting a Root Cause Analysis. The first step is to figure out exactly what happened. This is the time to collect information and to investigate to gain a clear picture of the incident. The second step is to determine what should have happened in an ideal situation. The third step is to determine the causes and contributors. Were there factors or a single direct cause that contributed to the event?
Asking why five times is a principal part of the third step which includes not accepting the first answer you get but to continue asking why until you determine the actual cause. The fourth step is to develop causal statements. The way to create casual statements is to determine the cause, the effect, and the event. The fifth step is to recommend actions and the sixth and final step is to write a summary to share in order to help prevent the incident from occurring again (Institute for Healthcare Improvement, n.d.).
CAUSATIVE AND CONTRIBUTING FACTORS
The most effective and comprehensive way to analyze the causative and contributing factors to the task scenario is to conduct a Root Cause Analysis. The first step is to determine what happened. Mr. B was a 67-year-old male admitted to the emergency room for a left-dislocated hip after he suffered a fall at home. On duty, that day was Registered Nurse J, an LPN, a secretary, an emergency room physician, Dr. T, and a Respiratory Therapist was available as well. Mr. B’s pain was 10 out of 10 meaning he was in severe pain. Mr. B also had a history of taking a narcotic pain medication called Oxycodone. When Mr. B arrived at the ER there were two patients being cared for, one waiting for discharge and one with pending lab results. Both patients had been triaged and cared for. Mr. B needed to have a procedure to correct his dislocated hip which required him to have sedation for pain control and relaxation.
Dr. T instructs Nurse J to administer conscious sedation medication. Mr. B is given an initial dose of 5 mg of Diazepam and 2 mg of Hydromorphone which fails to provide the level of sedation Dr. T feels is appropriate for the procedure, so those same doses are repeated for a total of 10 mg of Diazepam and 4 mg of Hydromorphone. Dr. T makes note that after he reviewed Mr. B’s medical record that his weight of 175 lbs. and already taking narcotic pain medication contributed to the difficulty in achieving the desired sedation results with less medication.
Mr. B is now sedated adequately, and the procedure successfully concludes with Mr. B still sedated, stable and in no distress. At this point, Mr. B is not on any additional oxygen and the ER receives an alert from the paramedics that they are on their way with a patient in respiratory distress. Nurse J places an automatic blood pressure (BP) monitor on Mr. B set to cycle every 5 minutes and a pulse oximeter.
Mr. B’s son is permitted to sit at the bedside at this point. BP and oxygen saturation are both stable and Mr. B remains without supplemental oxygen, ECG or oxygen monitoring. Meanwhile, in the ER, both Nurse J and the LPN are treating the new ER patient and are busy discharging the other two patients. The ER lobby is now becoming increasingly full. At this point, Mr. B’s oxygen saturation machine alarms showing a reading of 85%. The LPN comes into the room briefly, resets the alarm and repeats the BP reading. Nurse J is now fully managing the critical new patient when Mr. B’s son comes out of the room informing the nurse that the alarm is going off again.
Nurse J enters the room and discovers that Mr. B’s BP is 58/30, oxygen saturation is 79% and there are no respirations, nor a heart rate detected. An emergency code is called, and Mr. B’s son is escorted to the waiting room. Nurse J immediately begins CPR and Mr. B is intubated so he can receive proper oxygen to his lungs. The code team arrives, Mr. B is hooked up to a cardiac monitor and is found to be in ventricular fibrillation, a life-threatening heart rhythm. Mr. B receives treatment restoring his heart rate to normal sinus rhythm, IV fluids, and medications are administered.
Mr. B received 30 minutes of interventions stabilizing his BP to 110/70, he’s not breathing on his own and is fully dependent on a ventilator. Mr. B’s pupils are fixed and dilated, there are no spontaneous movements and he is not responsive to stimuli. At the request of the family, Mr. B is transported via air transport to a tertiary facility for advanced care. One week later the hospital receives a call from the facility where Mr. B was transported to, he was deemed brain dead and his family had his life support removed. Mr. B consequently died.
The next step of an RCA is what should’ve happened. When Mr. B was admitted to the ER, his respirations were elevated at 32, his pain was 10/10 and he was in moderate distress which were all grounds for providing not only supplemental oxygen but also continuous BP, ECG, pulse oximeter and respiration monitoring. Mr. B should’ve been placed on a continuous BP monitor, ECG and pulse oximeter throughout the procedure to realign his hip and until he met very specific discharge criteria. After all, this was the policy for when a patient receives conscious sedation. As soon as the ER began to fill up either Nurse J or the LPN should’ve requested more help which was available. Next, when Mr. B’s oxygen saturation alarm goes off and read 85%, the LPN should’ve quickly assessed to be sure the reading was accurate and if so, then placed Mr. B on 2 liters of oxygen per nasal cannula as a nursing measure. The LPN then should’ve immediately notified Nurse J (Institute for Healthcare Improvement, n.d.).
Step 3 of the RCA cycle is to determine causes and step 4 is to develop casual statements. One contributing factor that resulted in this event included Mr. B already taking a narcotic for pain medication on a chronic basis. Already taking a narcotic for pain control meant he might require more medication to achieve an optimal sedation level. A causative factor was receiving more sedating medications in the first place which likely caused a decrease in respirations dropping Mr. B’s oxygen level causing the life-threatening heart rate. Other contributing factors were Nurse J becoming busy with the incoming critical patient and the ER filling up with patients without enough staffing to cover. Step 5 of the RCA cycle is making a list of recommendations to prevent something similar from taking place again. Finally, the sixth step is to make a summary to share for the team to define the next steps (Institute for Healthcare Improvement, n.d.).
The proposed improvement plan would be providing a new training on conscious sedation monitoring to physicians and nurses that are involved in procedures requiring sedation. It’s vital to gain the support of the staff on why this change is necessary and, in this case, it’s because of a patient’s death that likely could’ve been prevented. There would be time to discuss the incident, so staff can realize things must change to keep this from happening again. There would be time to answer questions at many points during the training as well. Adding a double check system by both the doctor and the nurse would be initiated. The double check system would consist of adding to the five rights of medication administering: right patient, right drug, right route, right dose, right time and adding right monitoring to this list. The double check would have to be charted electronically and signed by both the doctor and the nurse before they would have access to the medications used for sedation.
The training would also provide additional education to LPN’s and other non-licensed clinical staff on monitoring vital signs. The staff would review the policy again on required monitoring and steps to take when alarms go off at the bedside. Since there was additional staff available as a back-up it would be important to go over the policies and procedures on how or when to request extra help.
The PDSA (Plan, Do, Study and Act) cycle would be most helpful in determining the best improvement plan. The first step would be to PLAN what the change will be, and, in this case, the training would be in the form of skills fair with scenarios like the sentinel event. The skills fair would provide lunch as an added incentive. The second would be to DO the training and have a skills fair as a small test with the nursing staff first to see how it goes.
It’s important during this step to also collect data and see if the new policy for continuous monitoring is followed by the nurses during structured scenarios. At the end of the skills fair, the nurses would fill out a short evaluation form detailing the effectiveness of the skills fair and for any suggestions. The third step is to STUDY the information collected so far into the PDSA cycle. This time is meant to analyze the data gathered. The final step is to ACT by determining if the skills fair will be expanded to physicians and non-licensed clinical staff or if it didn’t work at all or if modifications need to be made. Once the training is complete and the new process is being used out in the hospital it’s important to make sure the staff feel supported and have the tools to help maintain this change.
Kurt Lewin was a physicist and a social scientist who developed a change theory back in the 1940s to help understand organizational change which is still utilized today. There are three stages within his model as compared to melting a block of ice, unfreeze, change and refreeze. Using Lewin’s model, the first phase unfreeze is when you need to rationalize to the staff just why the change is necessary. In the above-proposed improvement plan, the preventable death of a patient is what would be used to get staff talking about what happened and why things need to change. It is important to allow for time to answer questions and concerns from the staff during this time.
The next phase is initiating the change. This is when the staff understands the procedure for conscious sedation monitoring will be different and have time to realize how beneficial this change will be in preventing unnecessary deaths. It’s very important to gain and keep the support of the staff for the change to be accepted. The final stage of Lewin’s change theory is refreeze, this is the time when the change has become a part of the everyday workflow and the new process is being used in the hospital. For the change to remain permanent a reward system helps to keep the new change in a positive light and sets a tone for new changes in the future (MindTools, n.d.).
GENERAL PURPOSE OF FMEA
Failure Modes and Effects Analysis (FMEA) is defined by The Institute for Healthcare Improvement as a “systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change” (Institute for Healthcare Improvement, 2018). In other words, FMEA is done as a preventable measure prior to an error occurring. It’s a way to think about what might go wrong and then put strategies in place to prevent mistakes. The FMEA process is used when a new process is being put into place, being changed or when looking at failures of a process that’s already in place.
STEPS OF FMEA PROCESS
The first step of the FMEA process is to find the process you are going to evaluate. This can be a process that is already in place or a new one. The second step is to put together a team from varying backgrounds which is commonly called a multidisciplinary team. The third step in the FMEA process is to make a list detailing the steps in the process that is being evaluated. The point of creating the list is so there is something visual to see. Next, identify the failures and causes of what might go wrong within each one of the steps on the list. It’s also important to identify what the effects would be as a result of the failures. The team would then rate the failure modes on the likelihood that the failure would occur, if it would be detected and what the severity might be.
The rating for the likelihood that the failure would occur and be detected is based on a scale of 1-10, one meaning not as likely to occur or be detected, however, a 10 would be very likely. The rating for the severity is also based on a scale of 1-10, meaning a 1 is less severe and a 10 is the highest severity. Next, you would calculate the Risk Profile Number (RPN) by multiplying each of the three failure modes and assigning a score with the lowest possible being a one and the highest being 1,000. The RPN score helps the team to know which of the failures would need to be analyzed first. The final step for the team is to come out with a list of actions in order to reduce the problems that the failure modes could cause beginning with the problems that have the highest RPN’s (Schneider, A., 2017).
FMEA TABLE: Please see the completed attached FMEA table.
The interventions of the proposed improvement plan would need to be tested. To begin with, the skills fair would be completed with the nurses first to see how it goes. Testing the improvement plan on a smaller scale allows the ability to make changes early in the process. The nurses would fill out an evaluation form with ratings on how effective the training was for the new procedure which would also include a place for suggestions. Since the nurses are in the primary role responsible for administering the medications, it’s best to obtain their feedback first before adding in the training for the physicians and other relevant staff members. Random observations would be made by management to see if the new process is being followed. Most important is to keep the communication going with all staff on the new process. Audits of the double check system in the electronic medication charts would be conducted to see if there are a doctor and a nurse both signing out conscious sedating medications.
Professional nurses can promote quality care and patient outcomes in ways of leading by example. Practice what you preach has commonly been used and it’s evidenced-based practices that lead to improved patient care and better outcomes. Nurses in management are also in leadership, however, it’s not just managing people that matters. Professional nurses can influence others by letting them know that they are listening and that they will help guide staff through areas of concerns with all aspects of patient care. Professional nurses can be a tremendous influence on implementing activities by making them fun, interactive and even rewarding. A reward system can set a positive tone and reinforce that evidence-based practices are utilized to continue to improve care for patients in all areas.
INVOLVING PROFESSIONAL NURSE IN RCA AND FMEA PROCESSES
The professional nurse is a valuable member of the multidisciplinary team during the RCA and FMEA processes. In the RCA process, the professional nurse can help break down each part of what happened and what exactly should’ve happened. They can provide a perspective that other roles cannot provide such as suggestions for different ways of professional practice while keeping the patient at the center. As far as the FMEA process, the professional nurse can help implement a new process and avert failures that could occur. They can brainstorm what might happen and put in place processes that can improve patient care overall.
Institute for Healthcare Improvement (2018). Failure Modes and Effects Analysis (FMEA) Tool. Retrieved from http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx
Institute for Health Improvement (n.d.). Patient Safety 104: Root Cause and Systems Analysis. Retrieved from http://app.ihi.org/lms/content/f99b4ea2-aeea-432d-a357-3ca88b6ae886/upload/ps%20104%20summaryfinal.pdf
Institute for Health Improvement (2018). Root Cause Analyses and Actions. Retrieved from http://www.ihi.org/education/WebTraining/Expeditions/root-cause-analysis/Pages/default.aspx
MindTools (n.d.). Lewin’s Change Management Model. Retrieved from https://www.mindtools.com/pages/article/newPPM_94.htm
Schneider, A. (Producer). (2017, October 31). Failure modes and effects analysis