...Pre-Steps for preparing for FMEA. Step 1: Select a process to evaluate with FMEA. This is where a process to be evaluated with FMEA is carefully selected. When selecting a process, special attention should be paid to the complexity of the process selected. A process that is not so large and complex is preferred to a large and complex process. For example, select ‘prevention of pressure sore’ instead of ‘pressure sore’ as a process to evaluate with FMEA. This is because evaluating pressure will involve causes, prevention, treatment and risks factors. Step 2: Recruit a multidisciplinary team. The team should include everyone that is involved in the process. All team members do not necessarily have to follow the process through the entire analysis. It is possible that a particular team member is only involved in a small, but crucial aspect of the process. For example, in the case of pressure sore, special mattresses in addition to turning and repositioning are needed for effective prevention of pressure sore in bed ridden patients. It will be necessary to have a representative of the vendor supplying mattresses as a part of the team. In this case, the vendor representative may not have to be involved in the entire analysis Step 3: The team meet together to list all the steps involved in the process. This is where every steps of the process is numbered and should be as specific as possible. This is not a rushed through step. It may not be possible for the team to achieve...
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...A. The sentinel event was related to respiratory arrest secondary to conscious sedation procedure. There were several factors that played a role which included high patient census, poor staffing, alarms dismissed by staff members, patient was left unmonitored, and no supplemental oxygen initated prior to the procedure. When the patient was pulseless no CPR was initiated until the code team arrived and critical interventions were delayed by the emergency room staff. The patients medication reconciliation or history weren’t reviewed by the emergency room physician. Tripple doses of intravenous valium and dilaudid were given without a lapse in time. The patient was elderly and on chronic oral opioid medications. “Normally these types of medications are administered with low doses and titrated per patient’s sedation level. Patient, monitoring or sedation level weren’t assessed between doses. This event is known as a sentinel event. In any situation that causes injury, or death a root cause analysis must be completed and reported to the Joint Commission. B. To implement a change in the conscious sedation procedure a team or committee needs to be established. All staff in the emergency room can become active participants by joining a committee or subcommittee. These main categories may include patient characteristics, task factors, individual staff members, team factors, work environment, and organizational management (IHI, 2014)...
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...providers are required to work in collaboration and include patients in the process of care. Nurses form the core of health care delivery in all facilities. The role they play in the coordination of care is essential for the professionalism of care providers. In the process of care delivery, it is important to understand the medical history of the patient to determine the most appropriate interventions to employ. Care providers should employ interventions that are besides guaranteeing positive health outcomes address the needs and interests of the patient. It is important to include family members in the treatment program since they understand the patient and his needs better. This paper employs Root Cause Analysis approach together with the Failure Mode and Effect Analysis to determine the impact of the events that resulted in the death of a patient Mr. B. A. Root cause analysis The principal purpose of the Root Cause Analysis is to conduct an evaluation of the highest level of the problem to identify the actual cause. In the case scenario, the root cause analysis rules out the possibility of inadequate patient assessment as a contributor to the factors that resulted in the death of the patient (Andersen, Fagerhaug & Beltz, 2009). The patient arrived at the facility complaining of severe pain in the hip region and the left leg. The nurse in charge conducted a routine check for vital signs including blood pressure, weight, and heart rate. Most of the patient's vital signs were...
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...providers are required to work in collaboration and include patients in the process of care. Nurses form the core of health care delivery in all facilities. The role they play in the coordination of care is essential for the professionalism of care providers. In the process of care delivery, it is important to understand the medical history of the patient to determine the most appropriate interventions to employ. Care providers should employ interventions that are beside guaranteeing positive health outcomes address the needs and interests of the patient. It is important to include family members in the treatment program since they understand the patient and his needs better. This paper employs Root Cause Analysis approach together with the Failure Mode and Effect Analysis to determine the impact of the events that resulted in the death of a patient Mr. B. A. Root cause analysis The principal purpose of the Root Cause Analysis is to conduct an evaluation of the highest level of the problem to identify the actual cause. In the case scenario, the root cause analysis rules out the possibility of inadequate patient assessment as a contributor to the factors that resulted in the death of the patient (Andersen, Fagerhaug & Beltz, 2009). The patient arrived at the facility complaining of severe pain in the hip region and the left leg. The nurse in charge conducted routine check for vital signs including blood pressure, weight, and heart rate. Most of the patient’s vital signs were normal...
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...RTT1 Task 2 Never events are serious medical errors that are often preventable. When such events transpire, it is necessary to fully assess the situation so that these errors can be prevented in the future. Root cause analysis (RCA) is a tool employed by healthcare facilities to analyze adverse events and the systems that lead to them. A. Root Cause Analysis “A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals” (AHRQ, 2012). The emphasis of RCA is on error prevention. It is a structured process of gathering data regarding the event, analyzing the information, and finding solutions to the problems to prevent reoccurrences. A team consisting of the charge nurse, a physician, a respiratory therapist, a pharmacist, hospital administrators, and patients not involved in the case is assembled to work through the process. The team begins by interviewing patients and staff involved to gather as much vital information as possible. Once all necessary information is compiled, the team works together to get to the root(s) of the problem. In the case of Mr. B, there were multiple issues that led to the adverse event as opposed to one root problem. In the process of defining the problem, several causal factors were identified. The error was a result of both facility and human error. Mr. B, a 67-year-old patient, presented to the small, six-room, rural hospital ED due to severe...
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...Root Cause Analysis Root Cause Analysis (RCA) is a process that pinpoints vital or root aspects that determine variation in conduct which includes the result or possible result of sentinel events. (Cherry, B., & Jacob, S. 2014). In the scenario with Mr. B., who was admitted to the Emergency Department (ED) after a fall with left leg and hip pain and was given conscious sedation for a hip reduction that resulted in respiratory arrest and subsequently cardiac arrest. There were several causes of this sentinel event. Hazards include the understaffing of the department and the high census of the ED coupled with a high acuity patient that arrived during Mr. B.’s sedation. More staff on duty, including RN’s and MD’s, could have changed the outcome for Mr. B. Some of the errors that occurred are; staff members ignoring the monitor alarm, the patient was left alone while still in the recovery phase, no supplemental oxygen administered to Mr. B. prior to the sedation, and the ED Physician reviewed Mr. B.’s current medications only after he gave orders for fairly high doses of narcotics and benzodiazepines for an elderly man. Also, reversal medications and CPR was delayed when Mr. B. was found pulseless and apneic. B. Improvement Plan The Emergency Department’s conscious sedation policy would be the first improvement to reduce the likelihood of adverse events like this from happening again. Specifically, changes in administering supplemental oxygen before the beginning of...
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...Organizational Systems and Quality Leadership Task 2 Jill Riccobono Western Governors University Organizational Systems and Quality Leadership Task 2 A. Root Cause Analysis A root cause analysis (RCA) looks at an event and considers what happened, why it happened what will be done to prevent it from happening again and how will we know that the changes made will improve the safety of the system. It takes into consideration causative factors, errors and hazards that led to a sentinel event. In this case it was a patient’s death. RCA should not look to place blame on people, but rather processes that need to be improved. The first step in a RCA is to identify what happened. In the scenario, presented in this task, the patient was over sedated and subsequently died. Step two is to identify why this happened. There were preventable causative factors, or errors, that led to this sentinel event. The hospital’s conscious sedation policy requires that the patient remains on continuous BP, ECG, and pulse oximeter throughout the procedure and there was no mention that this was performed at all throughout the procedure. It was not until after the procedure that Mr. B was placed on continuous BP and pulse oximeter, and at that time, the patient was left in the room, with only a family member while Nurse J attended to another patient. When the alarm is heard that the patient has low O2 sats, the LPN, enters the room and resets the alarm and repeats the B/P reading. His oxygen level...
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...Organizational Systems and Quality Leadership Task 2 Mark Woodard Western Governors University This paper will analyze the cause of the sentinel event which occurred to Mr. B, a sixty seven year old patient which presented to the emergency room with left leg pain. A root cause analysis will be necessary in this case to investigate the causative factors which led to Mr. B’s sentinel event. The factors in this unfortunate case weather they were errors in his care, or hazards in the system will be identified. The Change theory will be used to develop an improvement plan that will be used to decrease the chances of a reoccurrence of the sentinel event that happened to Mr. B. in the scenario. Root Cause Analysis A root cause analysis, is a system that is used to develop a plan that will identifying the causative factors of an adverse event and formulate a plan to decrease the occurrence or chances of a sentinel event. A team consisting of , a member of the hospital administration, a pharmacist, a respiratory therapist, a charge nurse or nurse manager, a physician, and a member of the family board should be brought together to perform a root cause analysis in this case. These team members would have a meeting to discuss the factors that led to Mr. B’s sentinel event. The first step would be for the team to begin interviewing the staff involved with the case to gather as much data as possible. The data that would be needed include, Mr. B’s...
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...Global Journal of Researches in Engineering: G Industrial Engineering Volume 14 Issue 2 Version 1.0 Year 2014 Type: Double Blind Peer Reviewed International Research Journal Publisher: Global Journals Inc. (USA) Online ISSN: 2249-4596 & Print ISSN: 0975-5861 Investigation of Sigma Level at the Stage of Testing Cement after Packing and Improving it using FMEA Approach By Md. Golam Kibria, Md. Enamul Kabir & S. M. Mahbubul Islam Boby Khulna University of Engineering &Technology (KUET), Bangladesh Abstract- Sophisticated customer demands and advanced technology have changed the way of conducting business. Financial condition of a manufacturing company largely depends on the defect rate of a product. Understanding the key features, obstacles, and shortcomings of the six sigma method allows organizations to better support their strategic directions, and increasing needs for coaching, mentoring, and training. The objectives of this paper are to study and evaluate processes of the case organization, to find out the current sigma level and finally to improve the existing Sigma level through decreasing defects. According to objectives, current sigma level has been calculated, manufacturing process analyzed and suggestions given for improvement. Especially in analyzing phase different analysis tools like Production Layout, Process Block Diagram, Cause and Effect Diagram, Cheek Sheet, Process control chart are used. FMEA is used as improvement tool. By using this it...
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...estimating a "typical value" for the distribution. To be specific, suppose that the analyst has a collection of 100 values randomly drawn from a distribution, and wishes to summarize these 100 observations by a "typical value". What does typical value mean? If the distribution is symmetric, the typical value is unambiguous-- it is a well-defined center of the distribution. For example, for a bell-shaped symmetric distribution, a center point is identical to that value at the peak of the distribution.For a skewed distribution, however, there is no "center" in the usual sense of the word. Be that as it may, several "typical value" metrics are often used for skewed distributions. The first metric is the mode of the distribution. Unfortunately, for severely-skewed distributions, the mode may be at or near the left or right tail of the data and so it seems not to be a good representative of the center of the distribution. As a second choice, one could conceptually argue that the mean (the point on the horizontal axis where the distributiuon would balance) would serve well as the typical value. As a third...
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...Organizational Systems RTT Task 2 Allison Vargus Western Governor’s University Organizational Systems RTT Task 2 Questions A The main goal of Root Because Analysis is to identify the policies and procedures in an agency that can be changed for the better. These changes are identified within an organization and a plan is put into place to prevent any reoccurrences of negative outcomes. RCA is defined as a “process for identifying the basic or casual factors that underlie variation in performance, including the occurrence of a sentinel event; it focuses primarily on systems and processes, not individual performance” (Cherry and Jacon, 2011, p. 442). A multidisciplinary team must assemble and pinpoint the exact causation of the problems. After the issues have been identified the next step is to determine refinements to prevent them from occurring again. Mr. B arrived at the Emergency Room after he had a fall in his home. The sixty-seven-year-old man arrived to the 6 bed, small town ER with his son and neighbor in a severe amount of pain in his left hip and leg area. There are several unfortunate reasons that lead to Mr. B’s demise. The information gathered to complete the RCA will determine the causation of this ill-fated situation. I will discuss these factors in further detail ahead. The first factor in this case I will discuss is the lack of education on hospital policies and procedures. Mr. B was placed under conscious sedation and therefore he should have...
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...SAMPLE EXAMINATION The purpose of the following sample examination is to provide an example of what is provided on exam day by ASQ, complete with the same instructions that are provided on exam day. The test questions that appear in this sample examination are retired from the CSSBB pool and have appeared in past CSSBB examinations. Since they are now available to the public, they will NOT appear in future SSBB examinations. This sample examination WILL NOT be allowed into the exam room. Appendix A contains the answers to the sample test questions. ASQ will not provide scoring and analysis for this sample examination. Remember: These test questions will not appear on future examinations so your performance on this sample examination may not reflect how you perform on the formal examination. A self-appraisal of how well you know the content for the specific areas of the body of knowledge (BOK) can be completed by using the worksheet in Appendix B. On page 2 of the instructions, it states “There are 150 questions on this 4-hour examination.” Please note that this sample exam only contains 75 questions. If you have any questions regarding this sample examination, please email cert@asq.org © 2009 ASQ ASQ grants permission for individuals to use this sample examination as a means to prepare for the formal examination. This examination may be printed, reproduced and used for non-commercial, personal or educational purposes only, provided that (i) the examination is not modified...
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...Healthcare organizations face tremendous challenges in addressing efficiency, cost, quality, staffing shortages and mounting pressure to raise salaries. To bolster lagging morale and improve retention rates, management must empower staff and effectively leverage existing resources. Tools and techniques that support these imperatives are critical to the success of modern healthcare organizations. Many problems in healthcare involve processes that require analysis and improvement, but do not require detailed statistical study. Instead of appointing a task force that may meet for short periods of time over weeks or months, Work-out offers a one-day to two-day concentrated problem-solving effort. What Is Work-out? Work-out is a problem-solving approach that involves employees in process improvement and addresses communication gaps between management and employees. A Work-out takes place in three phases: planning, the session itself, and implementation of the action plan. It starts by identifying an issue complex enough to require more than a simple decision, but not so complex as to require detailed statistical analysis. Background information is gathered and participants are identified. Next, the Work-out itself takes place. Typically 6 to 12 individuals who do the work meet for one or two full days. The Work-out usually follows two or three cycles of idea generation and prioritization: identifying the details of the process under consideration, examining barriers and finally...
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... Contents Contents 2 Introduction 3 Task 1 3 Task 2 5 Task 3 7 Task 4 8 Conclusion 8 References 8 Appendices 9 Introduction In this assignment I have taken on the role of a business improvement engineer who is responsible for leading a team to develop continuous improvement principles and techniques within the workplace. This will be done through the use of FMEA which will show my understanding of the crucial steps needed in the FMEA process; to improve quality, reduce cost, improved productivity of employees and increased customer satisfaction. Task 1 Failure Mode and Effects Analysis (FMEA) is a method designed to identify potential failure modes for a product or process, to assess the risk associated with those failure modes, to rank the issues in terms of...
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... Abstract Thousands of people die each year as a result of medication errors. Medication errors can be attributed to faults in both humans and medication use systems. Therefore, it is necessary to address resolutions to both of these predicaments. The anticoagulant heparin is amongst the most implicated medications. Thus, it has been documented in the top five high-alert medications. Two notable events that triggered recent interest in this topic are the heparin overdoses that occurred in California, associated with actor Dennis Quaid’s newborn twins, and those affecting neonates in an Indiana hospital. The Failure Mode Effect Analysis (FMEA) is a proactive approach to error prevention. Implementation of an FMEA system would serve as a crucial method that will help to recognize potential failures of a product or process before adverse events occur. FMEA can help identify where the use of technology can be implemented to facilitate the reduction of medication errors, especially pertaining to heparin as in this case. Studies have shown how technology, such as computerized heparin nomagram system (HepCare), smart pump infusion technology, computerized physician order entry (CPOE), and the bar coding system, can reduce medication errors. Expanding nationwide awareness of these methods should result in a significant decline of medication errors. Introduction Errors are unavoidable in today highly complex and technologically advanced...
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