Task 2: Root Cause Analysis and Failure Mode and Dynamic Analysis (FMEA)
For efficient service delivery, health care facilities have a duty of conducting a cause analysis (RCA) to respond to any situation at hand. Through such an approach to nursing, practitioners can perform a failure mode and dynamic analysis (FMEA) to help in reducing the likelihood of a process failing. As a method, RCA helps professionals in identifying the cause of problems or faults in a system. According to Davis et al. (2008), practitioners consider a factor as a root-cause when the removal of a concern impedes the final undesirable circumstances from recurring. Thus, through the elimination of a causal factor, various elements can benefit the outcome of a process. It’s thus hard to develop the recurrence of such a situation with certainty.
The case scenario in task 2 develops a classic case of failure demonstrated by the affected teams. There were many causative factors to blame in this scenario. When the patient was brought in, he was experiencing a 10/10 pain as a result of the fall. Physical tests were undertaken in the Triage, which included B.P, HR., R, and T. Everything seemed perfect except for the breath rate at 32 per minute. Respiratory therapy is available but it is not readily availed to Mr B. Medication is provided to regulate the same atorvastatin and oxycodone all in good will, but unfortunately, oxycodone worsens the breathe rate of the patient as well as inhibits the required sedation. This is one of the prevailing causal factors that probably led to the unfortunate death because this aspect was mostly ignored by nurse J and the physician. After the triage, he was moved to the emergency department. The weight of the patient impairs the sedation process. During a previous visit to the doctor, Mr B is found to have elevated lipids and cholesterol – a case that is exhibited by the swelling of his leg. This is another causative factor.
During the ED, none of the nurses who are well trained to handle this case show up to aid the patient in question. When the O2 saturation alarm is heard and clearly indicates “low O2 saturation” – at 85%, the nurse does nothing about the case. Later on, the patient is declared brain dead. If proper respiratory therapy was availed, perhaps the patient would not have died. Also, if the nurse would have responded appropriately as required to the low oxygen alarm, the death of the patient would have been avoided. The website “PSNet: Patient Safety Network” states that sometimes in a case scenario, it can happen that the root causes of a particular problem are two or maybe more as shown above. [“Write my essay for me?” Get help here.]
Process Improvement Plan
Several factors led to the death of the patient, these includes: poor staffing, high patient number in the facility, the patient left unmonitored, alarms dismissal by staff, and inadequate supplemental oxygen initiation before the procedure (Davis et al., 2008). Notably, at the time the patient was pulseless, the attendants initiated no CPR until the arrival of the code team, thus leading to delayed critical interventions by the emergency staff. Besides, the staff never reviewed the patient’s’ medication history at the emergency room. As such, the team administered triple intravenous doses of valium and Dilaudid without considering adequate lapses in time. Broadly, the team failed to assess the patient’s sedation process.
Change theory applicable to the process improvement plan
Lewin’s Change Management Model can be used to test the value of the plan. The theory states that for a company to succeed during a change, it must be broken down completely and presented as a new block that accommodates new needed changes. A case example here is with the staffing. The principles and ethicalities of nursing are to be revisited by all the workers in the hospital. The healthcare givers will be able to accept change in working hours and workloads. After this aspect, the change itself will occur where nurses will be motivated by their principles and ethics. The same procedure can be applied with the citizens in the rural area as they aim for better living standards.[Need an essay writing service? Find help here.]
Furthermore, change theory as, Armitage and Hollingsworth (2010) note, is a general approach or notion to change, which a medical staff finds to be convenient in developing the distinct concepts for changes, which lead to an improvement (Davis et al., 2008). According to Armitage and Hollingsworth (2010), Lewin’s Model of Change entails three steps of initiating change to enhance care quality. Motivation or unfreezing is the first step, and it aims at promoting communication while empowering the staff to be open to various working models.
Failure Mode and Effects Analysis (FMEA)
Should we follow the credited failure mode and effects analysis (FMEA), the plan might face some failures for example, in the event the citizens fail to embrace the plan. Some of them have very tight schedules and cannot understand the importance of using the less time available in reading the number of calories in a sample fast food. However, to avoid such a scenario a simple chart, containing a list of common food staff and their calorie-numbers will be availed for each resident thus promoting the success of the aspect in the plan.
Failure Mode Effect Analysis is a treasured tool or process, which is useful in reducing and eliminating defects. FMEA thus applies systematic methods in evaluating the processes for detecting where and how the process might fail while gauging the potential effect of the different types of failures. The tool then assists in identifying the segments of the process, which are in dire need of change (Davis et al., 2008). In the process, FMEA avails in-depth examination, thus outlining the steps followed and the diagnosis criteria.
The interdisciplinary team
The FMEA requires a team to achieve the desired success. Success is defined as the coming to an “end” of the root causes related to the effect. Obviously that is a complex process that requires different sets of people. An example of these is the interdisciplinary team consisting of the supervisors and the physician. This is the team that works round the clock to come up with ideas and enhance them. A team like this one will be handling the staffing organization. It is required to come up with ideas of how to encourage the nurses to work under the ethics and principles that will be provided. A multidisciplinary team for this process would include a pathologist, clinical nurse specialist, lead lab technician, anesthesiologist, and obstetrician to form part of the Failure Mode Effect Analysis team.
Steps for preparing for the FMEA
Gather a multidisciplinary team and assign them their specific roles. Make the team to collect and assess all the internal and external data as well as the scope of rehearsal and the clinical practice procedures as Board of Registered Nursing stipulates.
Preparing of the FMEA is a function that requires precision and vast knowledge of the company. However, the steps to forming a workable FMEA are quite simple:
- Select a process to analyze: this would be the betterment of healthcare in our rural homes.
- Charter and select team facilitator and team members: as explained above the process requires distinct members.
- Describe the process: explain to the team members what the issue at hand is and most importantly, what is required of them. Be specific and clear.
- Identify what could go wrong during each step of the process: identify the shortcomings of the procedure. For example, the rural populace might not take lightly the thought of lifestyle change.
- Pick which problems to work on eliminating: discuss ways in which this problem can be eliminated. For example, availing calories’ charts for the members of that area
- Design and implement changes to reduce or prevent problems: the team will come up with ways of carrying out the procedure at the lowest cost and with the least time required.
- Measure the success of process changes: have a grading system for the process so that if it fails to work out, you can notice early and change.
Application of the three steps of the FMEA (severity, occurrence, and detection) to the process improvement plan created in part B.
The three steps of Failure Mode Effect Analysis are detection, severity, and occurrence. Detection considers the ease with which to visualize a concern. Severity denotes the condition of the matter while event signifies the likeliness of an anticipated manifestation. Each team member is then assigned a numeric value called Risk Priority Number (RPN) for the prospect of detection, occurrence, and severity (Cherry & Jacob, 2010). Each failure mode is then assigned a numerical value of between 1 and 10. According to Armitage and Hollingsworth (2010), this digital grading puts a figure on a possibility that a failure would not be detected, the probability that a failure would occur, and the prospect of the damage or harm the failure mode may cause. This is shown in the table below.
||If some nurses are to be terminated from work- damaged reputation
||Villagers may not accept to change their lives
||The probability of the company influencing villagers to changing their lifestyle
||Very likely to be detected
||Not likely to be detected
Testing the interventions from the process improvement plan
I would test the intervention of the above process by analyzing how general it is. It should be applicable to many nurses – patient relationships in that, most of the cases of nurses doing a shoddy job are as a result of “forgotten” or rather ignored principles – a factor that needs continuous reminder. For this reason, I would apply the procedure in another case of associated with sentinel event.
The task directions help the practitioners to explain how they assess the interventions from the process of improvement strategy from part B to develop care. A team might have to be very explicit in describing how they test their development plan. Thus, the implementation of stricter protocols must be followed regarding conscious sedation and teams must conduct effective immediate procedural guidelines as stipulated by the contract. There must be adequate follow-ups on updates and reviews to enhance conscious sedation protocols to be considered by the ED staff (Cherry & Jacob, 2010). Usually, reviews go for every 90 days followed by annual updates. The annual educational update may consist of medication administration, a conscious sedation protocol, and familiarity with the mechanisms involved.[Click Essay Writer to order your essay]
Professional Nurse Functioning As a Leader in Promoting Quality Care and Influencing Quality Improvement Activities
A nurse can exercise her duty of caring for patients by leading the patients into a healthy lifestyle. She could encourage them to live right, eat right and have frequent balanced exercises – a very important aspect in the health of a patient. Thus, a nurse’s role is to provide a holistic care and to ensure adjustment in the day-to-day work setting. According to Davis et al. (2008), nurses are vital in health care system since they are the first people to identify a crisis and call for medical attention. Thus, nurses should be unremittingly cultured on best evidence protocol. Systems must encourage their nurses to follow hospital rules and help in maintaining safer patient care in communities and hospice environments.
Armitage, A, & Hollingsworth, N. (2010). A practical guide to failure mode and effects analysis in health care: making the most of the team and its meetings. Journal of Quality Patient Safety, 36(8), 351-8.
Cherry, B., & Jacob, S. (2010). Contemporary nursing: Issues, trends, and management (5th Ed.). St. Louis, Mo: Mosby.
Davis, S., Riley, W., Gurses, A., Miller, K., & Hansen, H. (2008). Failure modes and effects analysis based on in situ simulations: A methodology to improve understanding of risks and failures.