Organizational Systems and Quality Leadership Task 22 C489

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Western Governors University *

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C489

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Health Science

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Feb 20, 2024

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docx

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1 Organizational Systems and Quality Leadership Task 2 Western Governors University

2 A. Is an organized approached to understand the causes that resulted in a harmful event. Root cause analysis provides a retrospective view of the error that occurred to result in a harmful event focusing on faults in the system rather than blame (IHI, 2019). 1. According to the Institute for Healthcare Improvement (IHI) there are 6 steps most commonly used in implementing a root cause analysis. Step one consists of the RCA team recall what happened by describing the series of events accurately and entirely to organize and clarify all information about the event. Sometimes a flow chart can be created to help organize the information received. In step two the RCA team determines what should have happened by determining what an ideal situation would have looked like. In step two it can also be helpful to create a flow chart based on the information collect under ideal conditions to compare to the flow chart created in step one. In step three, the RCA team pinpoints the cause by asking why five times to get to the root cause of the event. This step helps the team to determine the factors that lead to the event by examining the direct and indirect factors that contributed to the adverse event. In this step it is encouraged to use a fishbone diagram which helps to explore possible causes of certain effects. Step is when the RCA team develops a causal statement. Step four is when the RCA team develops a causal statement. A casual statement is a 3-part statement that explains factual factors that contributed the negative outcome for patients and staff. Step five focusing on the preventing the recurrence of the event. In this event the RCA generates a list of changes that they think will prevent the error under review from happening in the future. There are several recommendations that fall in similar categories that some can define at strong, intermediate and weak actions. So, actions are more effective than other with dealing with the root causes of an error. Step six deals with the

3 RCA team writing a summary report that may contain a flowchart to use to engage the key players in this analysis. To clarify information about the event to help to encourage the next steps in improvement in patient care (IHI, 2019). 2. This scenario consists of a 67-year-old man name Mr. B who was brought into the emergency department by his son after sustaining a ground level fall. Which caused him to have pain to his hip that he stated was 10 out of 10. Mr. B’s vital signs were stable upon arrival. After Nurse J evaluated Mr. B and informed Dr. T of her findings, Dr. T then proceeded to evaluate Mr. B. Dr. T gave orders to Nurse J to administer medication to Mr. B for the purpose of achieving skeletal muscle relaxation to perform left hip reduction on Mr. B while he is under sedation. Nurse J administered 5 mg of diazepam IV push at 4:05 p.m. and hydromorphone 2 mg IV push at 4:15 p.m. per Dr. T order. After 5 minutes Dr. T gave Nurse J an order to administer another dose of hydromorphone 2 mg IV push and diazepam 5mg IV push. Within 20 minutes of administration of the first does of analgesic Mr. B appeared to be sedated to Dr. T’s satisfaction at 4:25 p.m. After the bedside procedure was performed by Dr. T, Mr. B was left in the room to rest while being on continuous pulse ox monitoring and blood pressure monitoring every 5 minutes. Mr. B’s vital signs started to decline Nurse J was alerted of it by the alarms, but no intervention or notification of the physician was taken place. By 4:43 p.m. Mr. B’s B/P 58/30 and O2 saturation is 79% and no pulse could be felt so a stat code had been initiated. Mr. B had to be intubated and eventual had to be transported by flight to a tertiary facility for advanced care, Mr. B later died. This sentinel event was attributed to respiratory arrest secondary to conscious sedation. There were several factors that lead to this event such as: Alarms being dismissed, more time in between

4 analgesic medication administration, no oxygen supplementation given to Mr. B prior to the initiation of conscience sedation, Mr. B was not on continuous ECG monitoring to inform the nurse of the change in rhythm, influx of new patients into the ER, lack of staff, Dr. T did not review Mr. B’s medication history of opioid use nor was he aware of his weight before giving orders to the nurse to administer the analgesics, Nurse J did not notify Dr. T of Mr. B’s decreasing O2 saturations nor did she administer oxygen to Mr. B. Supplemental oxygen is part of most hospital protocols when a patient is under conscience sedation. Mr. B required conscious sedation specific monitoring in between does’ of IVP analgesics administration to monitor his vital signs, level of consciousness, orientation status, O2 saturation and pupils. All of these were contributing factors that led to the sentinel event, a root cause analysis is needed to prevent an event a reoccurrence of this event. B. The process improvement plan that would likely decrease the reoccurrence of the scenario would be to develop a collaborative task force team. This team can consist of 4 to 6 members from varies departments such as a pharmacist, the manager of ER, clinical educator, manager of the post anesthesia care unit, and 2 lead ER staff nurses. This team would come together first to try to describe what actually occurred as accurately as possible, by doing reviewing chart audits, incident reports made, feedback gathered by staff. Then the team will modify the scenario to imagine if how things would have resulted under idea conditions. The team would then, gather and review data on the event that occurred such as: work environment, characteristics of the patient, relating task factors, individual staff members, organizational management, team factors. The team could use a cause and effect, or a wishbone graph to help organize the data found to be able to

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