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 sedation medications, assessing the patient’s home medications before ordering of sedation medications, assessment of the effects of the medications given prior to administering the next dose. Another improvement is better staffing the ED, especially in historically busy times. A RN could be assigned to be the float nurse and be the nurse who will take patients requiring moderate sedation. CPR should be reinforced with all of the staff that takes care of patients. To implement this change in the moderate sedation policy, there should be a systematic approach. A team should be assembled to look at the causes of the sentinel event and what lead up to it. They identify what happened and what should have happened. Then they can identify the causes. A fishbone diagram can be used with Charles’ Vincent’s seven categories of components that contribute to error and influence clinical practice. These include; patient characteristics, task factors, individual staff member, work environment, organizational and management factors, and institutional context. ( IHI,2014). This team would change the moderate sedation policy and obtain better staffing. The team would consist of ED RN’s, ED MD’s, Pharmacist, and the ED Nurse Manager. A Pharmacist might also be helpful for knowledge of the medications. This team would assess the documentation and discuss ideas for an outline to change the policy. When the policy is decided on it needs to be clear and have firm roles for the staff involved in the moderate sedation. These changes could be that the MD must perform an assessment of the patient and the medications that the patient is currently taking before the procedure. The pharmacy could calculate the dosages of the medications for the appropriate dose. The float nurse needs to be assigned only to this patient with no interruptions and never leaving the patient alone once the procedure has begun until the patient is fully recovered. Recovery criteria should stated clearly in the policy. Psychologist Kurt Lewin states that there are three stages to organizational change; unfreezing, change or transition, and re-freezing. The purpose of this model is to pinpoint issues that can inhibit change from happening. There might be the belief from hospital management to increasing staff in the ED because of more cost and not understanding any need for more staff. One way to unfreeze this thinking could be distributing data on research on how adequate staffing leads to better patient outcomes and increased patient satisfaction. Increased patient satisfaction has shown to generate more business for the hospital.
Changes to policies in a hospital department can be difficult to change for the nursing staff, who will be implementing the change. A barrier to the new moderate sedation policy change might be that the staff nurses will believe that they will not be supported during a one to one sedation by the ED administration. The nursing administration will need to show that they are serious about supporting the nurses and this new policy because research shows that any improvement on quality in a healthcare organization needs to come from the top. ( Draper, D., Felland, L., Liebhaber, A. and Melichar, March 2008, The role of nurses in hospital quality improvement.) The hospital administration, in addition to the ED management ,will need to support this quality improvement to the policy by getting the ED physicians to support the policy and getting one or two nurses who are in strong favor of this change to champion it to their colleagues. They can also solicit input from the ED RN’s for the best way to implement this policy and brainstorm ideas. This is part of the unfreezing part of change theory.
When the change actually happens in the ED, in respect to adequate staffing of the department, some of the staff will need some support and guidance with this transition. The nurse management should be on hand for questions about job roles and responsibilities and how the flow of the department will change. There might be frustration from some staff that is expressed and this is an opportune time for the managers to listen and get some ideas for how the new process can be improved upon. When the department does have a moderate sedation patient, the flow nurse can be dedicated to that patient alone and there could be a manager there to answer questions and be used as a resource. This is the second step in the change theory which is the transition period.
The next part of this change theory of Kurt Lewin’s is the re-freezing step. This is the final step in regards to the change is the staff’s new normal behavior. When these new improvements have been adopted by all of the staff then this is the time where the staff has a meeting to discuss how the process is working and to make sure that the extra staff is now considered to not be extra but the standard. This might be a time where staff also gets feedback from the managers in regards to how their patient satisfactions scores are to see if this quality improvement plan is impacting the patients and outcomes.
C. FMEA
Failure Modes and Effective Analysis (FMEA) is a process that is designed to identify possible failures before they occur and to calculate what the consequences of these failures would be. This process helps determine what pieces are most required for change. (IHI Open School: Root Cause and System Analysis, Failure Modes and Effects Analysis (FMEA) Tool).
C.1,2,3
The first step in preparing for the FMEA is to select a process. This would be the new moderate sedation policy. The second step would be to gather an interdisciplinary team. This would include RN’s, Physicians, Pharmacists and the Emergency Department Nurse Manager. The clinicians that work day in and day out are very important to this team because they know the intricacies of how the system really works. The Nurse manager is important because their perspective is to see the whole picture not just individual roles in the ED. People with different expertise make the best teams.
The third step is for the team to list out the steps in this new policy. A flowchart would assist with listing and ordering the steps. The team members would have to come to an agreement on the steps in the new process. The fourth step is for the team to think of possible failure modes and causes in the new process. This includes both major and minors failures.
For the fifth step, the team would designate a number for the probability of the failure to happen, the probability of the failure being found out and the severity if the failure actually happened. This is called the Risk Priority Number (RPN). Numbers are from 1-10 with 1 being very likely to be discovered and 10 not very probable. The three scores for severity, occurrence and detection are multiplied together for an overall RPN. Step seven is to assess the results of the RPN scores. The failure modes that have been identified as having the highest scores are the ones to be chosen for process improvement. (IHI, Failure mode effects analysis tool, 2014)
The three steps of the FMEA are severity, occurrence and detection. With regards to the process improvement initiative of applying oxygen to all moderate sedation patients, if a failure was identified (no oxygen was administered at all), then the severity of not receiving oxygen would be assessed by the team. What is the impact on the patient if this happens? The team would assign a number for the severity impact to the patient.
In regards to occurrence in the FMEA, the team would assess how often the failure of not giving oxygen could occur. Causes would be listed by the team members and then a number would be assigned.
Last is detection in this three step process. The team would talk about how likely it would be to detect a failure before any effect or harm would befall the patient. These are all people with experience in different fields so this is not blind guesswork. These three numbers would then be multiplied together to achieve a Risk Priority Number (RPN).
C.4 Intervention
In order to see if the new interventions in the moderate sedation plan was making patient care better, I would use the Plan-Do-Study-Act (PDSA) for gauging results. This method tests change by devising it, trying it, examining the results and acting on what has been learned. For applying the PDSA model to the interventions that is planned in the ED, the first step is to state the objective of what the change is to accomplish and then create a plan. A small sample size would be tested, such as one patient. After the test is completed, unexpected challenges would be documented. Studying the data would begin. The team would meet to analyze the data and study the results. Any predictions made in the planning phase would be compared to the actual test results by the team. If something did not go well or needed to be modified, changes would be made and agreed upon. Then another test would be planned to see if the modifications helped. Then the PDSA cycle would begin again and until the process was acceptable the team members. Then the change would be applied on a bigger scale.
D. Key Role of Nurses
The professional nurse can function as a leader in promoting quality care by getting involved in their department and also in the hospital as a whole. The nurse has a unique perspective on the health care system, their hospital and their unit that they work in. Getting involved is by joining committees in the hospital that focus on improving patient outcomes and safe practices. Nurses greatly influence other nurses and the nurse could advocate for the idea that patient safety is a shared responsibility. The professional nurse can influence and promote quality care by educating themselves about evidence based nursing and becoming an advocate for safe patient care.