Root cause analysis (RCA) is a standardized process of identifying the root causes of a problem in order to find the appropriate solution. RCA process is based on the assumption that it is more effective to analytically prevent an issue from occurrence rather than seeking to treat the temporary symptoms or playing the blame game (Comeau & Adkinson, 2007). The process was designed to identify the areas where a mistake occurred in order to find ways to decrease the chances of an adverse event taking place again. A root cause analysis can be designed after a customer complaint, a medication error, or after an incident has been reported. The RCA team ought to be interdisciplinary, including all the parties that would be directly involved in the incident.
The first step towards conducting RCA as defined by IHI, involves identifying what transpired. The description of the incident should be as comprehensive and accurate as possible. A flow chart may be included to provide a clear picture of the process. The first step is commonly referred to as the fact-finding step as it seeks to establish how the mistake occurred. For example, medical records or incident reports are used to collect data about the event. Data collection must be done by all parties involved in the event (Boyer, 2001). The second step involves determining what ought to have happened. Using the flow chart indicating the right procedure or policy will help in establishing where the mistake occurred. Furthermore, a comparison of the actual sequence of events with the internal organizational procedures will certainly indicate the variance.
The third step involves finding the root cause. It is the step where the contributory causes leading to the mistake or error are identified. The cause and effect diagram, such as a fishbone, is used to establish the cause. Most RCA processes recommend constantly asking why to establish the exact cause of the problem. The fourth step is about developing a casual statement linking the causes and effects of the problem (Comeau & Adkinson, 2007). It is also critical to define accountability for change or implementation in order to bring change. The changes in procedures or policy should include measurable outcomes in order to be effective.
The fifth step involves generating a list of recommendations to prevent the reappearance of the event. The list can include factors such as simplification of the processes, use of checklists, standardization of procedures and policies, and insurance. Timelines for evaluating the effectiveness of policy changes should be introduced at this stage (Boyer, 2001).The sixth and final step involves the creation of a summary document clarifying the process and how the error occurred throughout the organization. Disseminating the information in a hospital setting, for example, minimizes the occurrence of the error in the future hence increasing staff morale and patient satisfaction.
Part A2
Referring to our scenario, there is one obvious problem that speaks out, and applying the RCA process can lead to a positive outcome for the patient. After successfully medicating the patient for a reduction of the pain in the left hip, he was continuously placed under oxygen and blood pressure saturation monitor. Once the emergency department became congested due to more incoming patients, an alarm brought the licensed practical nurse into MR. B’s room where she reset it and repeated the blood pressure reading. In this scenario, step one alone tells us that there was a problem and requires that we determine what had happened. The problem is that the LPN reset the alarm without knowing what it was pertaining to. Step two requires that we determine what ought to have happened (Comeau & Adkinson, 2007). The LPN ought to have acknowledged the alarm then notified the RN of what she had seen. At this point, the RN could have taken action and told the LPN to apply oxygen to the patient. She would also have reported what the next blood pressure ought to be from the trend. From the procedure, it would have been easy to tell Mr. B’s progress and the level of recovery.
The third step is to determine what caused a breakdown in the process. From the scenario, it is clear that the RN and LPN got overwhelmed with the high volume of incoming patients into the emergency department after the sedation procedure of Mr. B’s reduction of left hip pain. The internal policy required the RN to continuously monitor the patient’s blood pressure, ECG and pulse oximetry to the point where the patient met the discharge criteria. The influx of patients, coupled with the patient suffering from respiratory distress, made it difficult for the RN to provide care for all patients. The fourth step involves developing a casual statement. Here, we must consider the facts about the case that led to negative outcomes. The casual statement will constitute three parts; the causes, the effects, and the event. The casual statement would look like this; the death of Mr. B following the reduction of his left his was in part due to the influx of patients in the ED, which caused a breakdown in the policy of the care provided (Boyer, 2001). The fifth step should involve simplifying the communication process between staff. The provision of education on the most effective chain of communication will help to address communication breakdown. Furthermore, updating the alarming technology will ensure there is patient safety. The last step is to summarize the changes in procedure and then to disseminate the information across the entire hospital. Outlining the important steps for providing care and ensuring patient safety will result in improved care.
Part B1
The Lewis change theory was created in the 1960s by Kurt Lewin and is considered the earliest of the change theories. It consists of three stages, including unfreeze, changes, and refreeze. According to the theory, a change in processes should occur when an error occurs within a healthcare organization (Cummings, Bridgman & Brown, 2016). A root cause analysis is carried out first, and then a process change is executed.
The first stage in the Lewis change theory is called unfreeze and requires the staff to gain a new perspective about the overall organizational plan, to unlearn old techniques, and be flexible to new possibilities to achieve their objectives. In our scenario, the RN, LPN, and the managing director are responding to events without a follow-up. By silencing the alarm, the LPN instinctively cycled the blood pressure without acknowledging wat the alarm pertains to (Cummings, Bridgman & Brown, 2016). As a result, the patient is not under continuous ECG monitoring as required. The patient’s heart rhythm cannot be determined when the alarm is unplugged. In order to initiate change, all the staff must be receptive to the proposed change in policy and procedures.
Change is the second stage in the Lewis theory of change. At this stage, all parties involved must understand that change is transitional and involves a change of tasks and responsibilities. As a result, a learning curve must be introduced both for the old and new staff. For change to occur, investment in new processes is important. In our scenario, the managing director needs to understand why change is important. For example, investing in a new ECG monitoring device is necessary to increase patient safety. The process change will help to detect heart problems early enough and to initiate treatment as quickly as possible (Cummings, Bridgman & Brown, 2016). During the change process, education for the staff is important to ensure that everyone is conversant with their new roles.
The third and last step of Lewis’s theory of change is known as freeze and is based on the assumption that change will only be effective if it is made a permanent process. After the change has taken place, and all staffs are competent in their new roles, the freezing stage gives them the opportunity to grow (Cummings, Bridgman & Brown, 2016). In our scenario, for example, once the MD, RN, and LPN have a more clear and precise policy to follow, patient satisfaction is achieved. In the end, patient satisfaction increases staff morale.
Part C1
The failure mode and effects analysis (FEMA) is used to establish and address the failures of a system prior to the occurrence of an adverse event. A FEMA process helps in creating new procedures and policies as well as identifying the unintended effects before implementation (Cummings, Bridgman & Brown, 2016). The FEMA tool has seven steps, including analysing, recruiting, describing the process, listing the potential failures, assigning numeric values to failures, evaluating, and improving the results.
The first step involves analysing the new process that needs to be implemented. The new process identifies the problematic section or area within a healthcare facility. The second step is about hiring an interdisciplinary team comprising of people who will be directly involved in the process to be analysed. The third step involves clearly defining the steps of the proposed process to ensure that the team members understand everything. The fourth step is about determining what could possibly go wrong in each step of the process (Duwe, Fuchs & Hansen-Flaschen, 2005). During this stage, the interdisciplinary team helps in acknowledging all the possible failures that could arise. The fifth step is about creating a list of problems that can be fixed and minimizing their recurrence to increase patient safety. The sixth step involves designing and executing change. This step is crucial as the team determines how best to create a process that minimizes the negative outcome on patients. The seventh and final step involves measuring success of the change process. Measuring the success is important as it tells the management to what extent the new process has worked.
Part C2 (FEMA Table)
| List 4 steps in your Improvement Plan Process | List 1 Failure Mode per step | Likelihood of Occurrence (1–10) |
Likelihood of Detection (1–10) |
Severity
(1–10) |
Risk Priority Number
(RPN) |
| LPN nurses must inform RN any time ED patient alarm rings | LPN fails to notify RN when patient alarm rigs | 4 | 5 | 2 | 40 |
| LPN must understand what patient alarm pertains to before resetting | LPN resets patient alarm without acknowledging what it pertains to | 3 | 6 | 3 | 54 |
| RN must monitor patients B/P and ECG continuously | RN forgets to monitor patient’s B/P and ECG continuously | 4 | 4 | 2 | 32 |
| All staff must follow the laid down communication protocol | RN and LPN breaks laid down communication protocol | 6 | 2 | 3 | 36 |
| 162 |
Part D
The primary method of assessing the interventions proposed in part B would be reviewing the medical records. A chart review would be useful in assessing the effectiveness of the triage system within the emergency department. Furthermore, analysing the data collected would indicate whether all information about the client was gathered, including B/P, oxygen and ECG saturation, O2, and RR. Post-procedure vital signs could also be included in the data collected to establish if the patient was arousal after the procedure and whether the patient had recovered adequately. In addition, random visual audits could be carried out on the emergency department staff as well as other critical areas where sedation cases are common (Boyer, 2001). Data could also be collected on alarms and other telemetry devices to address issues of fatigue. Using this kind of information will certainly bolster the care provided in the emergency department and optimize the care offered to patients.
Part E
Leadership is defined as the process of influencing others towards the achievement of the organizational goals. There are plenty of leadership styles, but ideally, coaching leadership is the most effective. This style focuses on developing the staff, analysing their performance, identifying their strengths and weaknesses, and then setting measurable targets for them. As a professional nurse, there are many areas where you can demonstrate your leadership skills (Morrison, 2014). For example, using the right policies and procedures allows a professional nurse to promote quality patient care and to ensure positive patient outcomes. Professional nurses ensure improved patient care through evidence-based practice. Evidence-based practice also ensures that care is provided to patients faster and in a direct manner. Quality improvement is achieved when patient information is compiled and disseminated to all departments in real-time. This ensures that patient information is easily accessible to all departments for various purposes.
Part E1
Including the professional nurses in the interdisciplinary teams is critical in the FEMA and RCA processes. This is due to their major interaction with patients when providing care. The professional nurse is the initial staff member who has direct contact with the patients. Their primary interaction with patients is important in the interdisciplinary team since we are dealing with patient care and how to improve the process (Varkey, Reller & Resar, 2007). Learning this course demonstrates the importance of a professional nurse in the change process and in the root cause analysis. Fundamentally, FEMA and RCA must involve a professional nurse since all patient care goes through the hands of a nurse. The recommendation and opinions of a nurse help in identifying the areas of failure since they are at the center of care provided to patients.
References
Boyer, M. M. (2001). Root cause analysis in perinatal care: health care professionals creating safer health care systems. The Journal of perinatal & neonatal nursing, 15(1), 40-54.
Comeau, E., & Adkinson, K. (2007). Promoting Quality Patient Care–Reducing Inpatient Mortality. Journal of nursing care quality, 22(1), 43-49.
Cummings, S., Bridgman, T., & Brown, K. G. (2016). Unfreezing change as three steps: Rethinking Kurt Lewin’s legacy for change management. Human relations, 69(1), 33-60.
Duwe, B., Fuchs, B. D., & Hansen-Flaschen, J. (2005). Failure mode and effects analysis application to critical care medicine. Critical care clinics, 21(1), 21-30.
Morrison, M. (2014). Kurt Lewin change theory and three step model-Unfreeze-Change-Freeze. Retrieved August 6, 2018.
Varkey, P., Reller, M. K., & Resar, R. K. (2007, June). Basics of quality improvement in health care. In Mayo Clinic Proceedings (Vol. 82, No. 6, pp. 735-739). Elsevier.