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C489 - Organizational Systems and Quality Leadership

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C489-Organizational Systems and Quality Leadership

SAT Task 2-1217

Western Governors University


Organizational Systems and Quality Leadership Task 2; SAT1-0517

A. Root Cause Analysis

        A root cause analysis is how an organization responds to an adverse event. According to IHI, a systematic approach to understanding the causes of an adverse event and identifying system flaws that can be corrected to prevent the error from happening again is a root cause analysis. (Orgrinc, Huber, & Vega, 2010) While focusing on the system causes to a problem, it enables a organization to see what all led to a problem instead of just the problem itself.

A1. RCA Steps

  1. Identify What Happened
  1. During this step the RCA team attempts to gather information and accurately describe what happened.
  1. Determine What Should Have Happened
  1. Once it has been identified what actually happened, it is now the team’s job to identify what could have happened if good procedures were in place and the caregivers followed them.
  1. Determine Causes (“Ask Why Five Times”)
  1. This step is the heart of the RCA process. The team can now identify what factors contributed to the event. The team should identify both direct and contributory factors. Questions that should be asked include, why did this happen, and then continue to ask why until a root cause is obtained.
  1. Develop Casual Statements
  1. A casual statement links the cause to its effects and then back to the main event that prompted the RCA team to begin with.
  1. Generate A List of Recommended Actions to Prevent the Recurrence of the Event
  1. At this step the RCA team should now identify actions to prevent occurrence of the same error again. Types of recommended actions could include:
  1. Standardizing equipment
  2. Ensuring redundancy, such as using double checks or backup systems
  3. Using forcing functions that physically prevent users from making common mistakes
  4. Changing the physical plant
  5. Updating or improving software
  6. Using cognitive aids, such as checklists, labels, or mnemonic devices
  7. Simplifying a process
  8. Educating staff
  9. Developing new policies
  1. Write a Summary and Share It
  1. At this point the RCA team will write a report that is easy for others to understand and share it with staff and other facilities to ensure the same mistake is not made twice. (Orgrinc, Huber, & Vega, 2010)

A2. Causative and Contributing Factors

        In the scenario. Mr. B died due to receiving a large amount of sedation which led to cardiopulmonary arrest. Multiple causes contributed to this horrible outcome. One cause was the amount of medication Mr. B received. In a total of twenty minutes Mr. B received 10 mg of diazepam and 4mg of hydromorphone. The peak and onset times of these medications were not thought of nor did the nurse think to refer to pharmacy for safe dosing of the medication before she administered them. Mr. B was also not placed on continuous blood pressure, EEG, or pulse oximeter throughout the procedure. Mr. B was only placed on the necessary equipment after the procedure once the RN knew she would be busy with the oncoming admit from EMS. If the EEG and pulse oximeter had been placed before the procedure began, it is possible that the change in heart rhythm would have been noted and resuscitation measures could have been started.

        Another issue with this scenario is that Mr. B was never placed on supplemental oxygen even when his pulse oximeter was noted to show a low reading of 85%. Mr. B was at a high risk of hypoxia due to being sedated. Even though Mr. B was placed on frequent blood pressure and pulse oximeter reading there was not a nurse available to monitor the readings and intervene if something was noted to be low or abnormal. When a nurse, the LPN, noted a low pulse oximeter reading of 85% she did not implement any intervention and also failed to mention the reading to the RN, which also contributed to the cardiopulmonary arrest and death of Mr. B.

        One of the errors that contributed to this event is the lack of staff. There is no excuse for the lack of staff on this particular day because additional backup staff was available. Once the RN knew another patient was coming by EMS to the facility the backup staff should have been called into work. At the point that the RN knew of the EMS patient there was already three patients in the emergency room with only one RN and one LPN. The RN knew both Mr. B and the EMS patient would both need close monitoring, but failed to call for backup which would have enabled the patients to remain safe.

B. Improvement Plan

        The first step in an improvement plan would be to create a team. This team could consist of multiple departments and personal including respiratory therapist, director of nurses or assistant director of nurses, medical director, and ER manager. The second step would consist of the team finding out all the facts that was involved in the event. The team could find out this information through interviews and medical records. The third step would include the team finding out what should have happened. The team could role play with multiple nurses with the same skill set Nurse J had in the scenario and note the differences in the conclusion. The fourth step would include determining the causes of the event. The team would need to include both the direct and contributory causes in order to fully understand the event. The fifth step would include developing a casual statement. The casual statement would relate the identified cause to the result of the event and also provide a reason as to why it happened. The sixth and final step would be to prepare the summary and share it with the staff members. In the summary the team could identify what went wrong and possible ways it could have been fixed in order to have a different outcome in situations in the future.

B1. Change Theory

        According to IHI, Kurt Lewin’s three stages include unfreezing, change, and freezing. The unfreezing stage consist of loosening an attachment toward a specific task. This stage will help employees understand why change is needed in hopes that staff will be compliant with the new changes. This stage could be carried out by the education department and managers of the floor. The staff needs to be educated on the event that took place, and how current policies could have led to the tragic death of the patient and how new policies are going to ensure that a event like this does not happen again. The second stage is change. This stage is where the team implements the new changes. At this point in the process the staff will need to begin implementing the new policies that management and the team have implemented. The staff can begin following checklist ensuring safe sedation use while performing a bedside procedure and start using accurate staffing ratios at times that the ER is the busiest. The management and team need to be available for the nurses to ask questions when unsure of the new policy during this step in the process. The third stage is called freezing. This stage consists locking the new change into place so it is implemented consistently and accurately by staff members. Once the new policies have been successfully implemented and possible changes have been made, the new policies will then become concrete and used in the organization permanently.

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