RUNNING HEAD: Task 2

C489 Task 2

Jeslin Mattathil RN

Western Governors University

3/26/2020
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A root cause analysis (RCA) is defined as a collective term that describes a wide range of

approaches, tools, and techniques used to uncover causes of problems. Root cause analysis is

part of a more general problem-solving process and an integral part of continuous improvement.

(What is Root Cause Analysis, 2020) This is done in occurrence of a sentinel even. This is used

to find out the root cause of the event and also find ways that this could have been avoided and

prevented. There are 6 steps used to conduct an RCA. The first step is to figure out what

happened. The most important part of finding the root cause is by first understanding how the

event even occurred. The event must be described completely and accurately. Step two is

determine what should have happened. The team must discuss what the most ideal situation

could have been. Step three is to determine the causes. This is where the team will determine the

factors that caused that contributed to the event. Experts recommend that the RCA team “ask

why five times” to get an underlying cause. There are seven different factors that can cause this

to happen such as patient characteristics, task factors, individual staff member, team factors,

work environment, organizational and management factors, and institutional context. Step four is

developing a casual statement using 3 parts, the cause, the effect, and the event. Step 5 is

generating a list of recommended actions to prevent the recurrence of the event. These

recommendations can fall under one of these categories: standardizing equipment, ensuring

redundancy, such as using double checks or backup systems, using forcing functions that

physically prevent users from making common mistakes, changing the physical plant, updating

or improving software, using cognitive aids, such as checklists, labels, or mnemonic devices,

simplifying a process, educating staff, and developing new policies. Step six is writing a

summary and sharing it. This step can be used to drive the next steps to improvement. (Patient

Safety, 2020) In this scenario there were many causative and contributing factors that leads to the
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poor outcome of Mr. B. Mr. B was sedated with diazepam and hydromorphone while also given

oxycodone. The combination of these drugs caused the likelihood of the outcome that occurred.

Some of the side effects were damage to the brain and breathing problems. Taking a note of Mr.

B’s age and past medical history, the medications that were administered to sedate him caused

these outcomes. Mr. B could have recovered if a better sedative that was more appropriate for

him was chosen. It could be said that the main cause for his death was the overdose of

hydromorphone and diazepam. Then the addition to oxycodone that was given with these

sedatives led to the patient to more complications. The recommendation that could have been

used was a checklist to ensure the right steps are taken with a sedated patient. The ECG was not

used on this patient at the time of administering these drugs so that could become a protocol

because they could have found the ventricular fibrillation earlier. Recommending having

continuous monitoring by a nurse after sedation could help decrease the chance of the sentinel

event occurring again. The last recommendation is to ensure that ER nurses aren’t over worked

and overloaded with cases. This allows them to be handle their patients safely.

A plan to improve and decrease the likelihood of reoccurrence of the scenario outcome is

very necessary. A team or committee needs to be formed to address this issue. All the staff in the

emergency room that day can be a part of that committee. They must first analyze that actions

that were taken that day. This can help point out the mistakes that were made in the event. It will

create a strong motivation to seek out better ways to handle patients that require conscious

sedation. A way of developing an improvement plan is using the change theory developed by

physicist and social scientist Kurt Lewin in the 1950s. This theory is three stages to explain the

change process. Using this theory, you can visualize how to incorporate human behavior into
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change management processes. These three stages are comprised of: unfreezing, change, and

freezing. The first stage is helping one adapt to change involves loosening their attachment of

their current practice. The second stage is the processes where change actually occurs. And the

last stage is when something has transitioned to a new way of being. (Learning Management

System, 2020). In this scenario, the whole team needs to see the importance of changing the way

sedation procedures are performed and how patients are treated before and after the procedure. In

addition to reviewing the current protocol that is instated for sedation, the team should look at

the overall care of those given medications that could potentially cause respiratory depression.

Due to the outcome that same of Mr. B, I am sure that the team will have no issues with making

a change to this. This was not only harmful to the patient and the family, but also the whole

organization. The hospital is liable for this event and this affects the reputation of the hospital.

Unfreezing stage is by reviewing the current sedation protocol and what is wrong with it. All

staff that was present during this event and staff that weren’t, need to be aware of this and have

an opportunity to voice their concerns. The hospital provided an educational module on

conscious sedation procedures but there should also be a printed copy that can be accessible in

the nursing station. This module should also revise if there are some inconsistencies. There could

also be a new protocol in which there is a longer time waited before administering the next dose

of opioids. Pulse oximetry should be a continuously monitored. There should also be proper

airway equipment and drug reversals at the bedside in state of emergency. There could also be

mock sessions to practice these new protocols to make sure that the staff feel the need to change

them. In this case, the LPN turned off the Sp02 alarm and did not report this to the RN or MD

which is really important. Maybe reeducating them on the importance of communicating this to

the people in charge could be applied here. There is also a need of having sufficient amount of
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staff available on the floor so that the RNs don’t feel overwhelmed with mount of patients to take

over. This is how patients are over-looked. We also need to ensure that RNs are calling on call

staff members when help is needed. There can be audits in places to ensure that these changes

have been made and are being practiced. This also can be used to make sure that it is running

smoothly and if there needs to be changes it can be addressed at that time. With all these tips, it

will be easier for the staff to apply these changes. The transition will not happen immediately but

over time these changes will be applied a 100%. Once they see that these changes have made a

difference in their patient outcomes staff will be more adamant on using these new protocols.

Refreezing will take place when the hospital has identified the barriers to sustain the changes

made . Employees will feel confident in using these new protocols and techniques on their

patience and feel the support from their leaders to continue to provide safe and competent care

for their patients. Making sure employees feel safe to voice their concerns during their education

and training is very important to ensure their cooperation. A good reward system of appreciating

the staff on a monthly basis meeting can be really appreciated. Making sure there is an open line

of communication makes the staff trust their leaders.

Failure modes an effect analysis is a technique that evaluates, identifies, and eliminates

possible failures issues and errors related to a system design process even before they start.

Teams use FMEA to evaluate processes for possible failures and to prevent them by correcting

the processes proactively rather than reacting to adverse events after failure have occurred. This

emphasis on prevention may reduce risk of harm to both patients and staff. (Failure Modes and

Effects Analysis, 2020) There are seven steps to develop a FMEA which include pre-work and

assemble the FMEA team, Path 1 development (requirements through severity ranking), Path 2
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development (potential causes and prevention controls through occurrence ranking), Path 3

development (testing and detection controls through detection ranking), action priority and

assignment, actions taken/ design review, and re-ranking RNP and closure (Introduction to

Failure Mode and Effects Analysis, 2020). The steps defined by Institution for Health

Improvement (IHI) in the PDSA cycle are: plan, do, study, and act. Plan: plan to collect data on

how to reduce or prevent adverse effect of respiratory depression while being monitor in the ER

under conscious sedation. Do: try out the test on small scale. Perform this in a short period of

time during the busiest times of the ED. Study: designate time to review and the data and study

the results. This could be a biweekly meeting of the FMEA team. Act: make appropriate changes

based on what has been learned from the data collected. Plan a test on a bigger scale. Test it for a

month for the whole day. See attached FMEA Table.

We can test the changes of the interventions that were used by the Plan-Do-Study-Act

cycle. We can look at all the changes that were implemented to see if there were any changes

made in the quality care of the patients. The Plan-Do-Study-Act (PDSA) cycle is a great way to

test the change that is made by planning, trying the change, observing the results of the change,

and acting on what is learned from the result and process. It is also very important to analyze the

expected results with the results that have been seen and then deciding if there is further changes

that need to be made.

Professional nursing can competently demonstrate leadership in promoting quality care,

improving patient outcomes, and influencing quality improvement activities. Nurses have the

opportunity to be part of committees that focus on quality improvement process that use
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evidence-based practices and making sure these changes are applied. They can also educate other

nurses and staff to improve patient care. Nurses have the tools to ensure that policies are being

followed throughout their department and making sure the resources are available to for staff to

use. Nurses can also help with making sure there is sufficient number of nurses available to assist

in increased patient census and critical situations. They are also the first to notice changes in

patients before the physician. They can hold meetings with all the staff to ensure there is open

communication with all the interprofessional collaboration team members. Nurses play a critical

role in hospital quality improvement because nurses are the primary caregivers in the healthcare

system. Nurses play a key role in RCA and FMEA processes because they are the first ones to be

able to spot the gaps that are found in patient care. Nurses are leaders in setting the tone in the

environment where staff can uphold their expectations. Nurses are such huge part of patient care;

they are impacting physicians and practitioners in efforts to improve quality patient care.

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Reference:

Failure Modes and Effects Analysis (FMEA) Tool: IHI. (n.d.). Retrieved from

http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx

Introduction to Failure Mode and Effects Analysis (FMEA). (n.d.). Retrieved from https://quality-

one.com/fmea/

Learning Management System. (n.d.). Retrieved from http://app.ihi.org/lmsspa/#/6cb1c614-884b-

43ef-9abd-d90849f183d4/ea07c796-a771-4713-8bd8-520188b6c793/lessonDetail/2adf747a-

862f-4862-ab0c-561318f05b67/page/1

Patient Safety 104: Root Cause and Systems Analysis. (n.d.). Retrieved from https://srm--

c.na127.content.force.com/servlet/fileField?id=0BE0c000000LYai

QI Essential Toolkit: Failure Modes and Effects Analysis (FMEA). (n.d.). Retrieved from

https://srm--c.na127.content.force.com/servlet/fileField?id=0BE0c0000009CfC

What is Root Cause Analysis (RCA)? (n.d.). Retrieved from https://asq.org/quality-resources/root-

cause-analysis