Running Head: ORGANIZATIONAL SYSTEMS­TASK 2
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Organizational Systems­Task2
Western Governor’s University
Elizabeth Shaw
July 3, 2016

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A. Root cause analysis(RCA) is a type of incident analysis that is used after an adverse event or near miss. It takes a systematic approach to determine the causes in order to identify areas of improvement in the system to prevent future adverse events(IHI, 2016).
An interprofessional team should be formed that should include all levels of the organization who are knowledgeable about the process that was involved in the incident. For this RCA team members should include the LPN, RN, emergency department physician, emergency department manager. A member of the risk management and or the quality improvement team should be on the team. In many RCA it is also valuable to have a patient on the team. Once this team is formed, members should agree to fill roles on the team. These roles include team leader, advisor, recorder and team members. Once these roles are established the team should identify what happened. Team members should collect information about the event.
In collecting the information, it is important to conduct interviews and review medical records.
The team should describe the facts of the sentinel event. The team should consider all causative factors, hazards and errors. In this scenario, several errors and hazards are present. Errors in this scenario were that the nurse failed to monitor the patient according to the hospital’s sedation policy, an alarm was ignored and a patient was given multiple doses of a medication without allowing proper time in between doses. Some hazards in this scenario include the high census and low staffing in the emergency room that day.

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Next, both direct causes and contributing factors should be identified. In this step of the RCA is to ask “why” each of the causative factors occurred. “Why was staffing so low in the ED that day”. “Why was Mr. B not monitored until he returned to baseline?”, “Why was the alarm on the monitor dismissed?”, “Why was the available nursing staff not called to help”? “Why was
Mr. B’s opiate tolerance not considered?”, “Why wasn’t CPR initiated before the CODE team arrived”? A fishbone diagram could be used. A fishbone diagram is a tool that is useful for identifying factors and grouping them. Some groups to include in this fishbone diagram would be institutional context, organizational and management factors, work environment, team factors, individual staff members, task factors, and patient characteristics. Within each of these categories there are many opportunities that exist that can lead to error(IHI, 2016). Some of the direct factors that lead to this sentinel event were alarms being disregarded, delay of life saving interventions such as immediate CPR and defibrillation. Contributing factors included high patient census and inadequate staffing, poor communication, a patient on chronic pain medication, patient elderly and the hospital’s conscious sedation policy not followed. Next, the data should be compiled and a root cause in the sentinel event should be identified. After analyzing all the data, considering the causative factors and events leading to the death of Mr. B, the team determines that the root cause was that due to unreliable means of monitoring during sedation process, Mr. B’s decline in clinical status went unnoticed. The final step in the
RCA is to plan and implement changes that prevent the sentinel event from reoccurring.
Changes should include educating the nursing staff about the importance of continuous monitoring during conscious sedation and when and how to intervene should the patient’s status start to decline. Putting forth a system for the emergency room nurses to quickly and easily

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contact the float nurse in the event of high census or patient acuity. Also important would be to educate all involved about assigning an ASA score to patients before being sedated to identify high risk patients. B. There are several steps in the improvement process to implement change. The interprofessional committee should identify improvement goals for conscious sedation policy and procedures. A clear, concise goal that provides guidance to participating staff is important.
To create a culture of change and willingness to improve patient care, staff members should be included in the process. Changes that can be implemented regarding conscious sedation is increased staffing, implementing a float nurse to help during times of high census or acuity. A check off list could be required to be completed by the ED physician and the nurse prior to the initiation of the procedure. The ED physician would be required to assign an ASA score to the patient prior to sedation. For every patient with an ASA score higher than 3 a consult with anesthesia would be required. Anesthesia would be required to clear the patient for sedation or develop a different plan of care for those that they consider high risk. The physician and nurse would be required to do a medication reconciliation prior to sedation and pharmacy would calculate dosing based on patient’s weight, age, history and current medications. In the event of inadequate staffing, the patient would be kept comfortable but the procedure would be delayed until appropriate staff were available and the sedation could be administered safely. It is important to remember that implementing change can be a slow process and requires the support of upper management to be successful. A list of objectives and measureable outcomes are

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necessary. Objects should be specific, measurable, appropriate, relevant and time bound. To complete the improvement process there should be appropriate suggestions to improve clinical practice, quality of care and patient safety(IHI, 2016). B1. Change theory is a general approach to change that is useful in developing specific ideas for change that lead to improvement. An improvement plan stems from a change theory and is put forth to decrease the likelihood of the sentinel event reoccurring. The change theory utilized for this scenario would be the Model for Improvement, developed by a group called the Associates in Process Improvement (IHI, 2016). This model has three fundamental questions. The first is
Aim, what is it that we are trying to accomplish? The second is Measures, how will we know a change is an improvement? The third is Changes, what change can we make to result in improvement? Once the change has taken place, the committee should evaluate and asses for any problems with the change. The committee could use a PDSA cycle to evaluate the success rate of the change. PDSA (plan, do, study, act)has four steps. The four steps are plan, implement, study the outcome and evaluate the success of the change. This helps determine if any changes are needed to the plan(IHI, 2016). C. Failure Modes and Effects Analysis (FMEA) is “a systematic, proactive method for evaluating a process that are most in need of change”(IHI). The. The goal of FMEA process is

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to increase the likelihood that the process improvement plan will not fail. . Analyzing the process by identifying the process flow is the first step of a FMEA. In this scenario the FMEA would be the new sedation monitoring process. The next step in the FMEA is to evaluate all steps of the sedation monitoring process to determine what could go wrong. These are referred to as failure modes. In this scenario, the failure modes would be improper monitoring of heart rhythm, respiratory rate, and oxygenation status during the sedation process. A ranking scale is used for each of the failure modes to determine the likelihood that harm would occur if anything went wrong (severity), the likelihood that what went wrong would happen (occurrence), and the likelihood that what went wrong would be detected (detection). Identifying interventions to improve safety for patients and reducing the probability of a reoccurrence of the event is the final step(IHI, 2016). The testing of the interventions from the process improvement plan would occur for 6 months in patients receiving conscious sedation in the emergency department. The ED nurses, float nurses and medical staff would be educated about caring for patients receiving conscious sedation and the new guidelines for monitoring patients receiving conscious sedation.
Emergency department physicians would receive additional training from anesthesia regarding assigning an ASA score to a patient. Medical records of patients in the emergency department who received conscious sedation during the 6 month period would be reviewed. Hopefully, with the implementation of these interventions, there will not be a repeat of this scenario.

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C1
Interdisciplinary team members that would take part in the FMEA would be the emergency department physician (Dr. T), the RN (Nurse J), the LPN, the nurse manager of emergency department, and the hospital’s chief nursing officer.
C2
There are a few steps that need to be completed in the preparation for the FMEA. A process needs to be selected. In this scenario the process would be the monitoring of patients receiving sedation in the emergency department. An interprofessional team should be established. This team should outline, in detail, the new process for conscious sedation in the emergency department. The assembled team should list and discuss anything possible that could go wrong with the new process and the corresponding causes. C3
There are three steps to the FMEA process. They are severity, occurrence and detection.
Severity is the likelihood that harm will occur if things don't go as planned. If the wrong dosage of medication is administered or if the patient is not monitored according to policy, how likely are those failures to occur? The likelihood that what went wrong would occur is called occurrence. How likely is it that the wrong medication dose will be given or that the patient will not be monitored properly during the sedation process? Detection is the likelihood that what went wrong will be detected. If the wrong medication dose or the patient is not monitored properly, how likely are those failures to be detected? The final step of the FMEA is the evaluation of the three steps.

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D.
Nurses play key roles in improving the quality of care in patients. In this scenario, the professional nurse could use Provision 3 of the ANA and apply it to practice. Provision 3 states
“The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient”(Fowler,M. 2008). The professional nurse has a responsibility to be involved in processes that improve the quality of care in order to protect the health and safety of the patient.
This should include the professional nurse being on committees and involved in processes to create change. The nurse should take a lead in investigating areas where improvement is needed.
The nurse should work with fellow nurses and other members of the healthcare team to identify specific areas for improvement and discuss and implement changes as needed.

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References Fowler, M. D. (2008). Guide to the code of ethics for nurses: Interpretation and application.
Retrieved June 30, 2016
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My Catalogs. (n.d.). Retrieved June 30, 2016, from http://app.ihi.org/lms/coursedetailview.aspx?CourseGuid=450435c3­f015­4541­943 2­46eb235461bb
My Catalogs. (n.d.). Retrieved July 04, 2016, from http://app.ihi.org/lms/coursedetailview.aspx?CourseGUID=41b3d74d­f418­4193­86a 4­ac29c9565ff1