-
Nursing- QUALITY INDICATORS
ANSWER
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 in the scenario attached 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, and 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 10 out of 10 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 is further evaluated and discharged from triage to the emergency department (ED) patient room. He is admitted by Nurse J. Nurse J finds that Mr. B has a history of impaired glucose tolerance and prostate cancer. At Mr. B’s last visit with his primary care physician, laboratory data revealed elevated cholesterol and lipids. Mr. B’s current medications are atorvastatin and oxycodone for chronic back pain. After Mr. B’s assessment is completed, Nurse J informs Dr. T, the ED physician, of admission findings, and Dr. T proceeds to examine Mr. B.
Staffing on this day consists of two nurses (one RN and one LPN), one secretary, and one emergency department physician. Respiratory therapy is in-house and available as needed. At the time of Mr. B’s arrival, the ED staff is caring for two other patients. One patient is a 43-year-old female complaining of a throbbing headache. The patient rates current pain at 4 out of 10 on numerical verbal pain scale. The patient states that she has a history of migraines. She received treatment, remains stable, and discharge is pending. The second patient is an eight-year-old boy being evaluated for possible appendicitis. Laboratory results are pending for this patient. Both of these patients were examined, evaluated, and cared for by Dr. T and are awaiting further treatment or orders.
After evaluation of Mr. B, Dr. T writes the order for Nurse J to administer diazepam 5 mg IVP to Mr. B. The medication diazepam is administered IVP at 4:05 p.m. After five minutes, the diazepam appears to have had no effect on Mr. B, and Dr. T instructs Nurse J to administer hydromorphone 2 mg IVP. The medication hydromorphone is administered IVP at 4:15 p.m. After five minutes, Dr. T is still not satisfied with the level of sedation Mr. B has achieved and instructs Nurse J to administer another 2 mg of hydromorphone IVP and an additional 5 mg of diazepam IVP. The physician’s goal is for the patient to achieve skeletal muscle relaxation from the diazepam, which will aid in the manual manipulation, relocation, and alignment of Mr. B’s hip. The hydromorphone IVP was administered to achieve pain control and sedation. After reviewing the patient’s medical history, Dr. T notes that the patient’s weight and current regular use of oxycodone appear to be making it more difficult to sedate Mr. B.
Finally, at 4:25 p.m., the patient appears to be sedated, and the successful reduction of his (L) hip takes place. The patient appears to have tolerated the procedure and remains sedated. He is not currently on any supplemental oxygen. The procedure concludes at 4:30 p.m.,and Mr. B is resting without indications of discomfort and distress. At this time, the ED receives an emergency dispatch call alerting the emergency department that the emergency rescue unit paramedics are enroute with a 75-year-old patient in acute respiratory distress. Nurse J places Mr. B on an automatic blood pressure machine programmed to monitor his B/P every five minutes and a pulse oximeter. At this time, Nurse J leaves Mr. B’s room. The nurse allows Mr. B’s son to sit with him as he is being monitored via the blood pressure monitor. At 4:35 p.m., Mr. B’s B/P is 110/62 and his O2 saturation is 92%. He remains without supplemental oxygen and his ECG and respirations are not monitored.
Nurse J and the LPN on duty have received the emergency transport patient. They are also in the process of discharging the other two patients. Meanwhile, the ED lobby has become congested with new incoming patients. At this time, Mr. B’s O2 saturation alarm is heard and shows “low O2 saturation” (currently showing a saturation of 85%). The LPN enters Mr. B’s room briefly, resets the alarm, and repeats the B/P reading.
Nurse J is now fully engaged with the emergency care of the respiratory distress patient, which includes assessments, evaluation, and the ordering of respiratory treatments, CXR, labs, etc.
At 4:43 p.m., Mr. B’s son comes out of the room and informs the nurse that the “monitor is alarming.” When Nurse J enters the room, the blood pressure machine shows Mr. B’s B/P reading is 58/30 and the O2 saturation is 79%. The patient is not breathing and no palpable pulse can be detected.
A STAT CODE is called and the son is escorted to the waiting room. The code team arrives and begins resuscitative efforts. When connected to the cardiac monitor, Mr. B is found to be in ventricular fibrillation. CPR begins immediately by the RN, and Mr. B is intubated. He is defibrillated and reversal agents, IV fluids, and vasopressors are administered. After 30 minutes of interventions, the ECG returns to a normal sinus rhythm with a pulse and a B/P of 110/70. The patient is not breathing on his own and is fully dependent on the ventilator. The patient’s pupils are fixed and dilated. He has no spontaneous movements and does not respond to noxious stimuli. Air transport is called, and upon the family’s wishes, the patient is transferred to a tertiary facility for advanced care.
Seven days later, the receiving hospital informed the rural hospital that EEG’s had determined brain death in Mr. B. The family had requested life-support be removed, and Mr. B subsequently died.
Additional information: The hospital where Mr. B. was originally seen and treated had a moderate sedation/analgesia (“conscious sedation”) policy that requires that the patient remains on continuous B/P, ECG, and pulse oximeter throughout the procedure and until the patient meets specific discharge criteria (i.e., fully awake, VSS, no N/V, and able to void). All practitioners who perform moderate sedation must first successfully complete the hospital’s moderate sedation training module. The training module includes drug selection as well as acceptable dose ranges. Additional (backup) staff was available on the day of the incident. Nurse J had completed the moderate sedation module. Nurse J had current ACLS certification and was an experienced critical care nurse. Nurse J’s prior annual clinical evaluations by the manager demonstrated that the nurse was “meeting requirements.” Nurse J did not have a history of negligent patient care. Sufficient equipment was available and in working order in the ED on this day.
REQUIREMENTS
Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. An originality report is provided when you submit your task that can be used as a guide.You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.
A. Explain the general purpose of conducting a root cause analysis (RCA).
1. Explain each of the six steps used to conduct an RCA, as defined by IHI.
2. Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome.
B. Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome.
1. Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan.
C. Explain the general purpose of the failure mode and effects analysis (FMEA) process.
1. Describe the steps of the FMEA process as defined by IHI.
2. Complete the attached FMEA table by appropriately applying the scales of severity, occurrence, and detection to the process improvement plan proposed in part B.
Note: You are not expected to carry out the full FMEA.
D. Explain how you would test the interventions from the process improvement plan from part B to improve care.
E. Explain how a professional nurse can competently demonstrate leadership in each of the following areas:
• promoting quality care
• improving patient outcomes
• influencing quality improvement activities
1. Discuss how the involvement of the professional nurse in the RCA and FMEA processes demonstrates leadership qualities.
F. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.
| Subject | Nursing | Pages | 13 | Style | APA |
|---|
Answer
Nursing Quality Indicators
Root Cause Analysis (RCA)
Purpose of Conducting RCA
The general purpose of conducting a Root Cause Analysis (RCA) is to determine why and how a patient safety incident has occurred (Haxby & Shuldham, 2018). A RCA helps in identification of what went wrong and the underlying reasons for their occurrences (Hibbert et al., 2018). Examples of safety incidents that may require a RCA include serious pressure ulcers, unexpected patient deaths, medication errors, some infections, and falls that result in injury (Haxby & Shuldham, 2018).
RCA Steps
Step 1: Step one involves identification of what happened: In this step, the investigation team attempts to describe what happened in a complete and accurate manner (Institute for Healthcare Improvement (IHI), 2020).
Step 2: Determination of what should have happened: In step two, the investigation team describes what would have happened in an ideal situation (IHI, 2020).
Step 3: Determination of causes: Factors that contributed to the occurrence of the incident are identified in this step (IHI, 2020).
Step 4: Development of causal statements: This step links identified causes to the effects with consideration of the major event that lead to initiation of a RCA (IHI, 2020).
Step 5: Generation of a list of recommended actions so as to prevent recurrence of the incident: Step five includes changes that need to be made to help prevent occurrence of similar issues in the future (IHI, 2020).
Step 6: Writing a summary and sharing it: Step six involves summarization of the course of the event and the associated action step to prevent similar cases in the future (IHI, 2020).
Application of the RCA Process in the Scenario
Step 1: Identification of what happened: The Emergency Department (EM) with its six-rooms was seriously understaffed. Mr. B did not receive person-centered care since Nurse J – the Registered Nurse (RN), the Licensed Practical Nurse (LPN), and Dr. T, the ED Physician were also engaged in other emergency cases. Lack of background analysis on whether Mr. B has overdosed oxycodone, for pain management, prior to hospitalization before administration of diazepam and hydromorphone may have contributed to severe respiratory depression and central nervous depression (Prescribers’ Digital Reference (PDR), 2020a, 2020b, 2020c). The rationale is that Mr. B’s respiration was already depressed (R 32) on admission due to suspected oxycodone overdose (PDR, 2020b). Despite this knowledge, he was administered diazepam and hydromorphone in high doses, which contributed to worsening of the respiratory depression (PDR, 2020B, 2020C). Mr. B was placed without supplemental oxygen therapy despite the fact that he was hyperventilating at the time (R 32). Besides, the LPN reset the oxygen saturation alarm when the patient’s oxygen saturation was 85% instead of putting him on supplemental oxygen support.
Step 2: Determination of what should have happened: History taking should have established whether Mr. B has used oxycodone to suppress the pain. Besides, the hospital should have properly staffed its EM as well as put patients such as Mr. B with depressed respiration under oxygen therapy. Lastly, but not the least, the LPN should have alerted the RN and Dr. T immediately after noting that the alarm was due to a drop in the patient’s oxygen level.
Step 3: Determination of causes: Factors that contributed to occurrence of brain death include combined respiratory depression following the use of oxycodone (suspected), high dose administration of hydromorphone and high dose of diazepam. Lack of oxygen support worsened the consequences of respiratory depression further (PDR, 2020a, 2020b, 2020c).
Step 4: Development of causal statements: Brain death is suspected to have occurred in the ED before Mr. B was lifted to a tertiary facility under life support machine. Suspicion of occurrence of brain death in the ED is supported by the fact that oxygen saturation level had dropped to 79%, blood pressure was 58/30, there was no palpable pulse, and the patient was not breathing when he was resuscitated and put under life support. Signs such as fixed pupils, no palpable pulse, no breath, no spontaneous movements, and no response to noxious stimuli were indication of brain death (Starr, Tadi, & Pfleghaar, 2020).
Step 5: Generation of a list of recommended actions so as to prevent recurrence of the incident
- Thorough history taking should be a requirement for all patients who are admitted to the ED.
- The ED should be adequately staff; there is need to hire more health professionals in the ED.
- The LPN and other staff members should observe the scope of practice. LPN should be informed of the importance of communicating emergencies and eventualities. The LPN should have not reset the alarm in the first place.
- Caution should be observed in administration of medications that can contribute to cardiopulmonary and/or central nervous system depression.
- Patients in coma should be assessed for possibility of brain death before referral to other facilities to reduce the cost of care.
Step 6: Writing a summary and sharing of it: Suspected use of oxycodone complicated by high doses of hydromorphone and diazepam contributed to worsening of cardiopulmonary function (PDR, 2020a, 2020b, 2020c). Decreased oxygen supply to the brain led to brain death (Star et al., 2020). Mr. B experienced brain death in the ED due to medication adverse effects, lack of supervision and urgent intervention, and lack of oxygen therapy.
Proposed Process Improvement Plan
Three phases of Lewin’s change theory including unfreezing, changing/moving and refreezing will be utilized in making of necessary changes to prevent occurrence of similar cases in the future. The unfreezing phase includes employing adequate staff, educating the staff on indication of oxygen therapy, appropriate response to alarms, and pathophysiology of brain death. The changing/moving phase will include provision of patient-centered care, team work in care of patients in EM, adequate staffing at any particular time, and training staff to communicate effectively. The unfreezing phase will involve cementing of the new changes and transforming the ED to adopt the new changes as part of its culture and tradition (Wojciechowski et al., 2016).
The Failure Mode and Effects Analysis (FMEA) Process
Purpose
The purpose of failure mode and effects analysis (FMEA) process is to evaluate a given process to identify how and where it might fail, impact of such a failure, and to identify parts of the process that ought to be changed (IHI, 2020a).
FMEA Process
FMEA process involves the following steps:
- Evaluation of steps in a process (IHI, 2020a).
- Failure modes – identification of what could go wrong (IHI, 2020a)?
- Identification of failure causes (IHI, 2020a).
- Failure effects – consequences of failure (IHI, 2020a).
Table 1. FMEA Table
|
List 4 steps in your Improvement Plan Process * |
List 1 Failure Mode per step |
Likelihood of Occurrence |
Likelihood of Detection |
Severity (1–10) |
Risk Priority Number (RPN) |
|
1. Adequate staffing of the ED by hiring more healthcare providers
|
The current financial situation in the healthcare organization may support additional staff. In addition, there may be shortage of healthcare professionals to be hired. |
6 |
9 |
8 |
432 |
|
2. Educating the staff on indication of oxygen therapy, appropriate response to alarms, and pathophysiology and assessment of brain death.
|
Resistance to change |
5 |
5 |
4 |
100 |
|
3. Adoption of effective communication strategies in patient care
|
Maintenance of status quo |
3 |
4 |
6 |
72 |
|
4. Caution in administration of medications to ED patients |
Encounter of patients from whom medication and drug history cannot be established, such as patients in coma. |
4 |
8 |
8 |
256 |
|
|
|
|
|
|
Total RPN (sum of all RPN’s): 860 |
Testing Interventions from the Process Improvement Plan
Appropriate methods will be used to test various interventions in the process improvement plan. Recommended staffing ratios will be used to determine the number of healthcare staff from different specialties that needs to be hired in the ED. An observational study will have to be conducted on whether the staff has adopted necessary changes as an outcome of healthcare staff education. Similarly, use of effective communication by the staff will be assessed using indirect outcomes such as teamwork and urgent response to emergency situations. Lastly, but not the least the rate of medication errors will be used to assess medication safety and appropriate prescription practices in the ED.
Demonstration of Nurse Leadership
Professional nurse should demonstrate leadership competence in promotion of quality of care, improvement of patient outcomes, and in improvement of quality improvement activities. The ability to promote quality outcomes can be demonstrated through adoption of transformational leadership style, which is characterized by creation of functional relationships and improved motivation of the staff members (Sfantou et al., 2017). A professional nurse should also ensure that nursing practice is effective, safe, equitable, patient-centered, and timely (American Nurses Association (ANA), 2015). The ability to lead improvement in patient outcomes is demonstrated by the ability of one to engage healthcare consumers, identify outcomes measures, provide culturally sensitive service, collaborate with others, modify expected outcomes, document outcomes, and evaluate the outcomes (ANA, 2015). In addition, nurses can demonstrate their ability to influence quality improvements activities by advocating for change so as to promote organizational performance, improve care outcomes, and solve issues (Wojciechowski et al., 2016). Nurses are also expected to participate in quality improvement initiatives, use innovation and creativity to enhance nursing care, and recommend strategies to improve nursing quality (ANA, 2015).
Involvement of the professional nurse in the RCA process and FMEA can be a demonstration of leadership qualities. Leadership knowledge and skills are required in conduction of RCA include leading investigations to identify causes of patient safety and other healthcare issues, evaluation of associated factors, and development of intervention plans. A professional nurse may lead a RCA team to help solve a given healthcare issue (Haxby & Shuldham, 2018). On the other hand, involvement of professional nurses in the FMEA results in promotion of clinical practice guidelines, which can in turn help reduce variation in practice and improve patients’ safety and care quality (Babiker et al., 2018).
References
|
American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Silver Spring: Author. Babiker, A., Amer, Y. S. A., Osman, M. E., & Al-Eyadhy, A. (2018). Failure Mode and Effect Analysis (FMEA) may enhance implementation of clinical practice guidelines: An experience from the Middle East. Journal of Evaluation in Clinical Practice, 24(1), 2016-211. https://www.researchgate.net/publication/322124292_Failure_Mode_and_Effect_Analysis_FMEA_may_enhance_implementation_of_clinical_practice_guidelines_An_experience_from_the_Middle_East Haxby, E., & Shuldham, C. (2018). How to undertake a root cause analysis investigation to improve patient safety. Nursing Standard, 32(20), 41-46. http://pdfs.semanticscholar.org/d019/aa172e71c93afd95a19b1d32dd09537d9fcc.pdf Hibbert, P. D., Thomas, M. J. W., Deakin, A., Runciman, W. B., Braithwaite, J., Lomax, S., Prescott, J., Gorrie, G., Szczygielski, A., Surwald, T., & Fraser, C. (2018). Are root cause analyses recommendations effective and sustainable? An observational study. International Journal of Quality in Health Care, 30(2), 124-131. https://doi.org/10.1093/intqhc/mzx181 Institute for Healthcare Improvement. (2020). Patient safety 104: Root cause and systems analysis. http://app.ihi.org/lms/content/f99b4ea2-aeea-432d-a357-3ca88b6ae886/upload/ps%20104%20summaryfinal.pdf Institute for Healthcare Improvement. (2020a). Failure modes and effects analysis (FMEA) tool. http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx PDR. (2020b). Oxycodone hydrochloride – drug summary. https://www.pdr.net/drug-summary/Oxycodone-HCl-oxycodone-hydrochloride-24333 PDR. (2020c). Hydromorphone hydrochloride – drug summary. https://www.pdr.net/drug-summary/Dilaudid-Injection-and-HP-Injection-hydromorphone-hydrochloride-490 Prescribers’ Digital Reference (PDR). (2020a). Diazepam – drug summary. https://www.pdr.net/drug-summary/Valium-diazepam-2100 Sfantou, D. F., Laliotis, A., Patelarou, A. E., Sifaki-Pistolla, D., Matalliotakis, M., & Patelarou, E. (2017). Importance of leadership style towards quality of care measures in healthcare settings: a systematic review. Healthcare (Basel), 5(4), 73. https://dx.doi.org/10.3390%2Fhealthcare5040073 Starr, R., Tadi, P., & Pfleghaar, N. (2020). Brain death. [Updated 2020 Feb 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538159/ Wojciechowski, E., Murphy, P., Pearsall, T., & French, E., (May 31, 2016). A case review: integrating Lewin’s Theory with lean’s system approach for change. OJIN: The Online Journal of Issues in Nursing, 21(2), manuscript 4. https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-21-2016/No2-May-2016/Integrating-Lewins-Theory-with-Leans-System-Approach.html
|