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 received increased assessments and observations. There was a policy in place that was not followed as directed. From the story told it appears the patient was neglected in terms of evaluating him before the procedure and kept a close watch of during and following it. Secondly, there should be guidelines put into place when the ER is inundated with patients and more staff is needed to care for the patients. These policies if properly followed could be used to avert any harm done to the patient in the care of the hospital. Secondly, the Emergency Room was short-staffed during that shift. Among the members on were a single RN, LPN, secretary, and doctor on the day the patient arrived to the ER. When Mr. B entered the ER that day, two other patients were awaiting care. Mr. B was evaluated and it was decided he needed a reduction of his left hip while the other patients had orders waiting for them. Subsequently, a forth patient was brought in respiratory distress while the other two patients were being readied to go home. All the while the patient waiting area was becoming crowded with other patients who were looking for care. It would have been of great benefit to have a system of staff who could have been reached to call for help, such as a nursing supervisor, or respiratory therapist. In these case it warrants some back up help for extra assistance and it is transparent that there were not enough staff to handle such a situation as this.
Question A1. There are a few major oversights in the case of Mr. B. One of the main errors was the lack of staffing with high acuity in the ER. It was stated that there were members of the hospital that could have been called for assistance to help. If this were communicated to the other members, the patients who presented to the ER could have benefitted and received proper care. As for Mr. untimely death, there are several things could have been remedied. His first evaluation by the ER nurse included an in-depth intake. His vitals were noted to Dr. T as within normal limits other than his tachypnea. The nurse also noted a record of his current medications. When the physician assessed Mr. B, he recommended that his left hip be relocated. This would involve sedation medication to help the patient’s anxiety and pain level. His first order was to give the patient five mg of diazepam IV. When the patient was re-assessed for sedation a mere five minutes later, the doctor found the effect insufficient. His next order, ten minutes later, was to give two mg hydromorphone IV which was given by the nurse on duty. The physician reassessed again five minutes later and decided that the effect was not sedating the patient to his liking and he ordered another five mg of diazepam IV and 2mg hydromorphone all by pushing the medication intravenously by nurse J. Shortly after the doctor gathered that he was most likely not feeling these effects due to his tolerance for oxycodone that is prescribed for back pain and his body mass. A doctor should review any current medications and allergies before an order is placed. The nurse who gave the medication should have sufficient knowledge about the medications given and question an order of several sedating medications administered in such a small amount of time. RxList (2015) describes, “when diazepam is used with a narcotic analgesic, the dosage of the narcotic should be reduced by 1/3rd and administered in small increments.” (p.4). The doctor did not follow this procedure in this case. Nurse B should also have been made aware when the patient took his last dose of medications, including his oxycodone, to establish if the medication was still having a sedating effect or not. If the patient had just taken his medication prior to coming to the ER it could increase the negative effects of over sedation. Being an elderly man also put the patient at an increased risk, “Extreme care must be used in administering diazepam injection, particularly by the IV route to the elderly because of the possibility that apnea/cardiac arrest may occur.” (RxList, 2015, p.4). ER nurses and doctors should be well versed in this information. Post procedure it was determined that the patient was in good condition and there were no apparent complications. The patient remained sedated while having his blood pressure, oxygen saturation, and ECG monitored as policy states. When the patient is no longer sedated and his vitals meet a certain criterion, the patient can be discharged home. These procedures were not followed as the vitals were never recorded. The nurse did not place the patient on the ECG when she left to handle another emergency, only monitoring his blood pressure and pulse oximetry every five minutes. While the nurse was caring for another patient, the patient’s oxygen level was 92% and his blood pressure 110/62. Oxygen should have been ordered to bring up his O2 level to at least 95%. Another staff member or a call to get additional help should have been put in place to help manage Mr. B’s care. A critical mistake was made following this when the LPN turned off an alarm that was sounding when Mr. ‘s B’s O2 level was 85%. The alarm is to alert the caregiver that there is low oxygen saturation so they can implement interventions to bring the oxygen level back up to a normal level. The nurse turned off the alarm and checked the patients’ blood pressure and left without remedying the situation. The LPN should have communicated this reading to the RN and given oxygen to the patient. The LPN could have been distracted or possibly did not realize the severity of the situation at hand. She could benefit from further education on how to assess sedated patients and vital sign monitoring and when and how to intervene. She also needs to communicate up the chain of command (RN, doctor, respiratory therapist) when there are vitals out of normal limits for further assistance. After this, the patient’s son notified the nurse that his dad’s monitor alarm was going off. When the nurse entered the room, the patient’s oxygen saturation was 79% and BP reading was 58/30. There was no pulse on palpation and the patient was not breathing. The team called a code blue and CPR was initiated. A cardiac monitor revealed the patient was in Vfib. They then intubated the patient and after a half hour, a normal sinus rhythm was established. The patient still required a ventilator to inhale oxygen. The patient was then transported to a second hospital, as the family wished. It was there they discovered the patient had no brain activity and the family decided to stop life support. Mr. B was then pronounced dead. Had the staff followed the policy for patients undergoing conscious sedation, he may still be alive. This would have allowed staff to intervene sooner with the proper interventions to prevent complications such as this.
Question B

Kurt Lewin’s theory of change occurs in three stages in order to receive lasting changes. According to Sutherland in 2012, it is put in place to “identify factors that can impede change from occurring; forces that oppose change often called restraining or static forces and forces that promote or drive change, referred to as driving forces.” (Lewins Change Management Theory sections, paragraph 1). Stage one is the unfreezing stage, then the moving stage, and lastly the refreezing stage. A step by step plan may be used to improve patient outcomes and prevent this unfortunate event from happening again.
Unfreezing stage The unfreezing stage is the first part of Lewin’s theory. It is a nurse’s job to gather data to properly determine the complications. The nurse will then evaluate where changes are to be adapted and communicate them to the team. The nurse in this situation may have a training to go over the policies and procedures about conscious sedation line by like to emphasize the areas which may have been neglected. The nurse would pinpoint if this problem was caused by a lack of comprehension of policy, training, or staffing levels that could be considered unsafe in order to properly follow it. There could also be some edits or additions to the policy that are needed that could be explored. It is important for the nurse to investigate these changes in order to improve patient safety. You could extend your investigation by including the whole hospital and surrounding hospitals for any ideas and any similar situated that have happened. Peers need to speak up if the policy is unclear or if they have any questions regarding the steps in the process. During this process it is important to involve everyone and brainstorm for input to implement realistic changes for the better. This also helps staff feel like they are being heard and valued for their opinions.
Moving phase The moving phase is the next step in which the nurse would describe why the changes are needed. They would reveal the plan, discuss the goal, and implement the adaptations. The nurse would act as support for staff during this time and evaluate the process and make any further changes as needed. They should act as a source of motivation for the staff because this is often the most challenging phase for people. People tend to resist change even if it for the benefit of themselves and others. The nurse should brainstorm ways in which to get staff to follow the change using positive reinforcement. In this scenario with Mr. B, several factors lead to his death and all need to be explored to rectify the situation so it does not happen again. These factors included inadequate staffing, communication between staff, monitoring the conscious sedated patient, doctors and nurse standard of practice, and education of the team regarding conscious sedation. In this case, there are several mediations to patient care that can be remedied to improve patient outcomes. The policy in place enforced that the patient is to be on continuous monitoring of ECG, oxygen saturation, and blood pressure. The patient is to be monitored until his readings met criteria that allowed him to be taken off and subsequently discharged home. The staff failed to monitor this information in Mr. B’s case, which could be reinforced with a training on how to use and read the equipment properly. If the staff understand the equipment and the readings and what they mean for the patient, staff will have a better grasp on when to intervene. Mr. B’s LPN simply turned off the alarm and did not give care to increase his oxygen level. The equipment should be made readily available to staff and monitored at regular intervals to make sure it is in proper working order. The policy should also specify that a designated staff member evaluate a patient undergoing conscious sedation at frequent time intervals. Staff should have a check list to go through and to document their findings at each assessment. This will help ensure compliance and the check list can have listed interventions for each abnormal finding. Another intervention can be that implemented is to have a backup call system for when the unit is in need of additional staff to help, especially with patients undergoing conscious sedation. This could help prevent a patient from deteriorating under the care of the hospital. The nurses practice standards are another example where change could be beneficial. The lpn in this situation did not intervene when the patients o2 saturation was below normal and an alarm was sounding. The RN also did not take proper measures to assess the patient post procedure. This warrants correction which the nurses receive a training upon hire and annually on how to assess and implement interventions when needed on a patient undergoing conscious sedation. The nurses also could utilize a scale in which to numerically rank a patient’s sedation level. It could list steps to take if a patient score is out of the normal acceptable level. This should include what to monitor for when patients are undergoing this procedure. Nurses should be aware of what constitutes dangerous sedation levels, which could include a heart rate of less than 50 or more than 120 beats per minute, an oxygen saturation level of less than 90%, and a rate of respiration less than ten (Cronrath et all, 2011). These changes should enable staff to act before the patient in put in danger. Another step to take could be to make some changes to the physician practice standards. Doctor’s preforming these procedures should also undergo training upon hiring and yearly and successfully complete these moderate sedation modules in order to perform in the ER. This will ensure the doctor is properly trained on any new information available to limit complications for patients. An additional adaptation would be to have the pharmacy double check orders for any medications that could be sedating and to have the physicians receive a training on indications, dosages, and frequencies of these medications in elderly patients. When implementing new policies and procedures it is vital to assist staff and encourage them to comply. The staff should be able to add input and come to management with any inquiries about these changes. If staff is inconsistent with following these changes, peers and administration need to continue training and give rationale for why these changes are necessary for patient safety. It would be beneficial for there to be an extra designated staff member to assist with training and allow the staff to ask questions. There could also be an extra staff member on when these changes occur to help support staff and allow them adequate time to work the policies and procedural changes. Staff need to feel supported when changes are made in order for success.
Refreezing Stage

The final stage is the refreezing stage. This stage helps to make these changes consistent and the work flow manageable. The nurse oversees that the change is being implemented and communicates to the hospital any feedback. The nurse should encourage and support staff to continue this process so is reaches long term potential for change. The administration also needs to continue to support its staff. The change also needs to be re-evaluated frequently to ensure the best outcomes for both patients and staff. Any concerns by staff should be considered and handled in a timely fashion. When this process is completed, any remaining problems should be ironed out and prevention of the original errors should be avoided, allowing patients to receive the best care possible.

Question C A description of failure mode and effects analysis includes, “a systematic process for identifying potential design and process failures before they occur, with the intent to eliminate them or minimize the risk associated with them.” (Cherry and Jacob, 2011, p.442)., It can be utilized in both young and old processes. When there is a process that is being enacted, FMEA can identify issues before it is brought to fruition. As far as existing processes, it may help to figure out why these changes would be for the positive. In the case with Mr. B, date obtained from FMEA could predict the chance that the improvement plan would succeed in keeping patients safe from being overly sedated and subsequently loss of life. These can help hospitals provide knowledge of all possible failure modes and the consequences they would have on the clients. This could help the hospital gain an understanding of any potential harm on the sedated patient. The first step would be to have a team establish and put forth proposals on how to prevent medical errors such as this. The team would highlight inadequacies on the floor, such as lack of training and shortage of staff. To rectify any deficiencies, the team would establish interventions to put into place. To successfully enact these changes, the FMEA team to take a leadership role and support staff during this phase. It is vital for staff to feel like they are being supported in order to prevent resistance to change which is a natural reaction for most. If the process includes all the necessary steps include proper assessment, identification of early warning signs that a failure mode has happened, and educating staff to identify them for early intervention (Institute of Healthcare Improvement, 2004), then success is likely to occur. The second step would be would be to assemble a team to develop the new policy. The administration will elect a facilitator to help recruit members and act as a director. The members should include staff from all disciplines of the hospital that will be effected by this change. For the best chance at a favorable outcome, the team must have firsthand experience with what has helped or hindered the previous policy. In this particular case, the team should consist of a doctor, nurse, a respiratory therapist, CNA, pharmacist, and a facilitator. A member from quality assurance, risk management, and the educational staff should be invited to join as well (Coranth et all, 2011).
Question C.1. It is possible to prevent deaths from occurring again after the case with Mr. B if necessary changes are put into place. The policy on conscious sedation needs to include new standards for nursing practice, physician practice, increased patient monitoring, as well as additional training and education (Cronrath et al., 2011). These changed should also define adequate staffing levels and enhanced exchanges of information between staff. These changes should enable staff to feel empowered and will hopefully promote a healthy exchange of ideas that will be implemented to enhance patient safety. It is important to trial run these changes that were set out in the moving phase for benefits and drawbacks. To test out these theories of change the FMEA team could gather data from the staff members on their opinion as well as having them demonstrate any knowledge they gained as a result. A survey poll could be used before and after the training to compare the how the patient outcomes could be enhanced. This would also allow for staff to express their beliefs towards the changes and give them a voice to state how they might feel about the new procedures (Hanafi, S. et al, 2014). The trainers may also want to give a test (written and demonstrative) to the staff to ensure proper understanding of the changes being implemented. Patient outcome data should be gathered and measured from before and after implementation to test for progress. This analysis is important to measure success for the FMEA team and will keep the team motivated if positive changes were made. This also gives an opportunity for the team to standardize these changes and double check the team is preforming adequately. The staff should be given adequate time to attend these mandatory trainings and be held accountable for their presence. Patient records should also be checked for any inaccuracies and missing information. This information will tell the team whether or not these changes need to be amended or if they are accomplishing the goals set by the FMEA team.
Question C.2. There is a several step process in preparing for FMEA. First you must prepare by choosing a topic to study and interpret. Next you need to develop a team to make a decisions regarding how to improve the current conscious sedation policy. Once this step by step list of improvement is done, there needs to be unanimous agreement on the process to move forward. The team then describes each ‘failure mode’ in every stage of the procedure. These failures modes list all possible complications. Lastly, the FMEA group must establish why these possible complications occur (Institute of Healthcare Improvement, 2004). The team is then to go on to the next step after completion.

Question C.3. The following step will be to rank the failures modes from most important to least. The team will need to decide together what to emphasize on. They will need to determine the probability of the mode taking place and what the patient outcomes would be in each case (QAPI, n.d.). Every failure mode will be graded by the team on occurrence, detection, and severity. Individual components will be scaled from 1 to 10, 10 being the highest ranking (Soliman and Hamed, 2014). Occurrence is defined by the measuring the possibility of failure happening. Detection is measuring the possibility of the failure being discovered when the failure mode happens. The severity is defined the level of consequence for the client if the failure occurs. After the failure has been given levels for each category, the next step is for the group to formulate the Risk Priority Number (RPN). The group will do this by multiplying the three numbers for a sum (Institute of Health Improvement, 2004). “The RPN gauges the risk associated with the potential problems identified during the FMEA process. It is useful for assessing risk and comparing components to determine priorities” (Soliman and Hamed, 2014, p. 13). This method will help guide the team to prioritize the need for change. In the case of Mr. B, a failure mode of high priority would most likely point to a lack of patient monitoring during conscious sedation. A patient undergoing conscious sedation has increased risks for decompensating and needs frequent vital sign and ECG checks by staff while being hooked up to a machine that checks these around the clock. If the patient’s results are out of a normal range, it is crucial for staff to intervene right away and try to solve the issue and communicate to others the findings. This step should bring the patients vitals and ECG back to baseline and allow for even more monitoring from the staff present. The fact that the staff did not perform this step in Mr. B’s case in a timely manner lead to the patient’s demise. The team would most likely determine that this would constitute a ten on the severity scale. The team would need to gather histories of similar cases for a frequency rank of patient who are improperly monitored. As for a detection rank, it is apparent that the staff did not manage to monitor the patient appropriately. After the information is gathered, it is rather obvious that there was lack of competence by the staff monitoring Mr. B., so a rank of about 4 or 5 seems reasonable. Upon investigation, the patient did not have his ECG and vital signs monitored continuously. In order to keep the patients safe during these procedures, it is important to attempt to remedy these failure modes and make all necessary changes.
Question C.4 To test for these interventions from the process improvement plan, the team must measure outcomes using Plan-Do-Study-Act cycle. This process will enable the team set goals and to measure outcomes that come with these changes. The first step is to plan a measurable and reliable outcome, such as to study cocious sedation patients undergoing treatment in the ER over three months’ time and measuring patient improvements (discharge from the ER) and patient satisfaction. The team will then study results and decide whether or not these implementations are worth continuing. If the results are inadequate, the team will need strategize a second improvement plan until perimeters are met.
Question D The nurse is on the front lines in healthcare today and can play a big role in improvement of patient outcomes. The nurse works as patient advocate for safety. “Ensuring that the client’s needs are met remain an important responsibility for the professional nurse” (Cherry and Jacob, 2011, p.542). A second role is for clear and open communications in nursing. The nurse needs to be able to coordinate pertinent patient information with peers and other disciplines in the work environment. Open communication with staff enables that the needs of the patient are met. Lastly, it is essential that the nurse be competent in her role as a caretaker. Nurses must use critical thinking skills and are constantly making proper assessments, preforming adequate interventions, and evaluating the effectiveness (Cherry and Jacob, 2011). If staff had utilized these skills to ensure safety for Mr. B, the outcome could have been a positive one. If Nurse J had used good communication to advocate for the patient after the doctor ordered a high amount of medication the patient may have survived. There was also a point where a lack of staff accounted for Mr. B not being properly monitored and a staff member should have recognized this and advocated for more help. In this scenario there were other staff handy so if this need was communicated, it would have allowed for close monitoring and sooner interventions. Nurse J gave incompetent care and removed herself from the room before evaluating Mr. B. She could have asked another staff to assess him or done so before going to help the other patient. The nurse was properly trained on how to care for patients in conscious sedation. Mistakes happen as no one is perfect, but it would have only taken a few moments to give the patient oxygen, attach his monitors, and assess ECG and vitals. The patient would most likely have survived had the nurse done what she was trained to do.

Resources:
API. (n.d.). Guidance for performing failure mode and effects analysis with performance improvement projects. Retrieved from http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/GuidanceForFMEA.pdf
Cherry, B., & Jacob, S. (2011). Contemporary nursing: Issues, trends, and management (5th ed.). St. Louis: Mosby Elsevier
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