...Organizational Systems and Quality Leadership Task 2 Kayla Meyer Western Governors University. A. Explain the general purpose of conducting a root cause analysis (RCA). The purpose of conducting a root cause analysis is to look back at an error that occurred, determine the direct and contributing factors to the error, and identify the flaws in a system that can be corrected to prevent this error from occurring in the future. A mix of different professionals from all levels of the organization comprises the team conducting the RCA. IHI 2019, Patient Safety 104. Explain each of the six steps used to conduct an RCA, as defined by IHI. 1. What is the difference between a. and a. Identify what error occurred, in the order of occurrence. 2. What is the difference between a'smart' and a'smart'? In ideal conditions, determine what should have happened, in comparison to what happened. 3. What is the difference between a'smart' and a'smart'? Determine the cause of the error by asking why, to find the root cause. Identify the other causes of the error by asking the health care team to explain their role in the event. Look into the workplace environment, and the management factors. 4. What is the difference between a.. A cause statement is developed. It explains how the list of...
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...to decrease the likelihood of a reoccurrence of the outcome of the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA) will be used to project the likelihood that the suggested improvement plan would not fail. Lastly, key roles nurses would play in improving the quality of care in the Mr. B scenario will be discussed. A. Root Cause Analysis A root cause analysis (RCA) is “a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event” (Cherry & Jacob, 2011, p. 442). The participants during the root cause analysis would be the emergency room physician (Dr. T.), the Mr. B’s LPN and RN (Nurse J) during the time of the sentinel event, the emergency room nurse manager, and the chief nursing officer (CNO) of the hospital. These members would meet in a root cause analysis meeting to discuss the causative factors that created Mr. B’s sentinel event. The first step in a root cause analysis on the sentinel event that caused Mr. B’s death is to gather the data surrounding the situation. Mr. B’s vital signs, including his blood pressures, important laboratory values, pain scores, and history of medication dispensed during the situation must be collected. The second step in a RCA is to describe the facts of Mr. B’s sentinel event. The third step in a RCA on Mr. B’s sentinel event is to ask why each of the...
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...Running Head: ORGANIZATIONAL SYSTEMSTASK 2 1 Organizational SystemsTask2 Western Governor’s University Elizabeth Shaw July 3, 2016 ORGANIZATIONAL SYSTEMSTASK 2 2 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...
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...A. Root Cause Analysis A root cause analysis (RCA) is 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” (Huber & Ogrinc, 2010). The root cause analysis is used to determine why the problem occurred in the first place and to identify the cause of a problem using a specific set of steps (Mind Tools, n.d.). The RCA team which consists of interprofessionals who are knowledgeable of the issues and processes related to the incident and the people who are involved in the incident should be formed first before the RCA meeting takes place (Huber & Ogrinc, 2010). In the given scenario, the team includes the emergency department (ED) physician (Dr.T), the RN (Nurse J), the LPN (Mr.B’s LPN), the risk manager, the ER nurse manager, the ER nurse educator, and the quality improvement professional. These members would meet and would discuss the causative factors, errors and hazards that caused Mr.B’s sentinel event. The root cause analysis process has five steps. The first step in conducting a RCA is defining the problem (Mind Tools, n.d.). In the given scenario, the problem is the unexpected death of Mr.B. The second step is collecting the data (Mind Tools, n.d.). It is very important to record and report the data as accurately and as completely as possible. Mr. B’s vital signs, pain scores, laboratory values, and history of medication administered during the situation must...
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...is to scrutinize the regrettable sentinel event of Mr. B, a sixty-seven-year-old patient who was admitted to a rural ED with left leg pain that he found unbearable. A root cause analysis will be used to exam the causative factors that led to this unfortunate sentinel event. Then I will identify the errors or hazards in the care of Mr. B. A change theory will then be utilized to establish a useful improvement plan that would hopefully decrease the chances of a repeat of the outcome in the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA) will then be used to project the likelihood that the suggested improvement plan would not fail. In conclusion key roles of the nurses involved in the care in the Mr. B scenario will be discussed. I have completed the RCA considering: causative factors, errors and hazards that had unfortunately lead to the death of the 67 year old patient that was brought to the ED. By performing the RCA we start at the beginning with the causative factors, we list staffing levels, who was there and who was not. The participants during the root cause analysis would be the emergency room physician (Dr. T.), the LPN and RN (Nurse J) the respiratory therapist who was in house but not in the ED at the time of this sentinel event, and the unit secretary. As we read through the scenario we discover that conscious sedation was used for Mr. B. Conscious sedation should never take place without a qualified Respiratory Therapist (RT) present. We know that...
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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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...Introduction: Healthcare organizations accredited by the Joint Commission are required to conduct a root cause analysis (RCA) in response to any sentinel event such as the one described below. Once the cause is identified and a plan of action established, it is useful to conduct a failure mode and effects analysis (FMEA) to reduce the likelihood that a process would fail. As a member of the healthcare team in the hospital described in this scenario, you have been selected as a member of the team investigating the incident. Scenario: It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient, arrives at the six-room emergency department (ED) of a sixty-bed rural hospital. He has been brought to the hospital by his son and neighbor. At this time, Mr. B is moaning and complaining of severe pain to his (L) leg and hip area. He states he lost his balance and fell after tripping over his dog. Mr. B was admitted to the triage room where his vital signs were B/P 120/80, HR-88 (regular), T-98.6, R-32, and his weight was recorded at 175 pounds. Mr. B. states that he has no known allergies and no previous falls. He states, “My hip area and leg hurt really bad. I have never had anything like this before.” Patient rates pain at ten out of ten on the numerical verbal pain scale. He appears to be in moderate distress. His (L) leg appears shortened with swelling (edema in the calf), ecchymosis, and limited range of motion (ROM). Mr. B’s leg is stabilized and then he is further...
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...Introduction: Healthcare organizations accredited by the Joint Commission are required to conduct a root cause analysis (RCA) in response to any sentinel event such as the one described below. Once the cause is identified and a plan of action established, it is useful to conduct a failure mode and effects analysis (FMEA) to reduce the likelihood that a process would fail. As a member of the healthcare team in the hospital described in this scenario, you have been selected as a member of the team investigating the incident. Scenario: It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient, arrives at the six-room emergency department (ED) of a sixty-bed rural hospital. He has been brought to the hospital by his son and neighbor. At this time, Mr. B is moaning and complaining of severe pain to his (L) leg and hip area. He states he lost his balance and fell after tripping over his dog. Mr. B was admitted to the triage room where his vital signs were B/P 120/80, HR-88 (regular), T-98.6, R-32, and his weight was recorded at 175 pounds. Mr. B. states that he has no known allergies and no previous falls. He states, “My hip area and leg hurt really bad. I have never had anything like this before.” Patient rates pain at ten out of ten on the numerical verbal pain scale. He appears to be in moderate distress. His (L) leg appears shortened with swelling (edema in the calf), ecchymosis, and limited range of motion (ROM). Mr. B’s leg is stabilized and then he is further...
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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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...Organizational Systems & Quality Leadership Name: Institution: Course: Tutor: Date: Organizational Systems & Quality Leadership Introduction The core objective of health care is to provide high-quality care to all patients to guarantee positive health outcomes. This principle is a major driver for the commitment of nurses and other care providers. Care 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...
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...y Name: Institution: Course: Tutor: Date: Organizational Systems & Quality Leadership Introduction The core objective of health care is to provide high-quality care to all patients to guarantee positive health outcomes. This principle is a major driver for the commitment of nurses and other care providers. Care 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...
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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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...The Unfortunate Hospital Experience for Mr. B Identification of Events * Mr. B presents to the Emergency Room with complaints of Left hip and leg pain * His son is at the bedside * Dr. T assesses Mr. B determining that he needs to set Mr. B’s hip at the bedside. * Dr. T orders moderate sedation * Mr. B takes oxycodone for chronic pain * Nurse J is assigned to care for Mr. B * Nurse J administers medications per Dr.T’s orders * 5 mg of Diazepam * Dr. T assesses Mr. B’s sedation level. Mr. B needs more sedation * Dr. T orders additional sedation medication * 2mg of Hydromorphone * Nurse J administers additional sedation medication per Dr. T orders * Mr. B is not fully sedated and Dr. T orders a 3rd dose of sedation medication * 5 mg of Diazepam and 2 mg of Hydromorphone * Dr. T assesses Mr. B. * Mr. B is fully sedated for the procedure * Dr. T reduces and sets Mr. B’s left hip * Mr. B’s procedure is completed. He appears comfortable and remains sedated * The Emergency Room receives an emergency dispatch call * Pt. in respiratory distress * Nurse J needs to respond to the call. * Nurse J puts a blood pressure cuff on Mr. B with 5 minute cycles and places the pulse oximeter on Mr. B * Son remains at bedside * Nurse J leaves the room to care for the patient in respiratory distress * Mr. B’s pulse oximeter alarm goes off “...
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...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 received increased assessments and observations. There...
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...1. How is quality defined? What is the goal of total quality management (TQM)? Why is TQM important? In general, quality may be defined as meeting or exceeding the requirements, needs, and expectations of the customer—whether or not those needs have been articulated. Garvin (1988) identified eight dimensions of quality: 1. Performance: measurable primary characteristics of a product or service 2. Features: added characteristics that enhance the appeal of a product or service 3. Conformance: meeting specifications or industry standards 4. Reliability: consistency of performance over time 5. Durability: useful life of a product or service 6. Serviceability: resolution of problems and complaints 7. Aesthetics: the sensory characteristics of a product or service 8. Perceived: quality: subjective assessment of quality based on cues related to the product Parasuraman, Zeithaml, and Berry (1988), identified five dimensions to service quality: 1. Reliability: ability to perform the promised service dependably and accurately 2. Responsiveness: willingness to help customers and provide prompt service 3. Assurance: employees’ knowledge, courtesy, and their ability to inspire trust and confidence 4. Empathy: caring, individualized attention given to customers 5. Tangibles: appearance of physical facilities, equipment, personnel, and written material TQM is a philosophy that involves everyone in an organization in a continual...
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