Essay Example on Root Cause Analysis of Sentinel Events in Healthcare

Introduction

Joint Commission is the government institution that accredits Healthcare institutions. These organizations are then required to conduct a root cause analysis (RCA) to responses to any sentinel event. A sentinel event is any unexpected outcome within a healthcare environment that may result to death, severe damage either physically or psychologically or both and the event is not related to the natural course of the illness (CAMH, 2013). Once the cause of the sentinel event is identified and an action plan established, the healthcare institution is usually advised to conduct a Failure mode and effects analysis (FMEA) to monitor as well as reduce the likelihood of the process to fail as well as establish another alternative in case the action plan fails.

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Root Cause Analysis (RCA)

Root Cause Analysis or commonly abbreviated RCA, is the medical process of investigating, identifying, and classifying the root cause of a sentinel event (unpredicted event) related to the safety, quality, health, production impact, and reliability of the patient's well-being in the hospital (Rooney & Heuvel, 2004). RCA is mainly established to answer the what, how, and why of the sentinel event happened (Rooney & Heuvel, 2004). There are six main procedures used when establishing and conducting a Root Cause Analysis (Bass, 2011).

A1. RCA Steps

The first step is to identify the event, problem, or issue to be examined and then gather preliminary data of the event. The issues can be sourced from health or incident reports, the health department citation, referral from risk management, complains either from the patient(s) or from family. Most often, healthcare facilities have a policy that guides them on the process of selecting an issue to undergo RCA. The second step is to create and charter a team that will conduct the RCA process. Team members will mainly comprise of key stakeholders such as experts in that particular field being investigated, research expert, and those that will be involved in the implementation process such as nurses and doctors. The third step is describing the findings based on the research done. The stage mainly involves organizing gathered facts revolving around the event being investigated. The fourth step involves identifying the factors that contributed to the event. Such factors as neglect, understaffing, limited facilities, and personnel, among other factors, are identified at this stage. The fifth stage is where the root cause is established. At this stage, the RCA team analyze each of the gather factors and pins out the specific cause of the event. Upon identification, step six now involves creating an action plan that includes implantation and reductions or eradication actions. Lastly, although not part of the six steps, is the evaluation aimed at measuring the success or failure of the established actions plan (Institute for Healthcare Improvement, 2018).

A2. Causative and Contributing Factors

Based on the scenario, the causative error was using "conscious sedation" without fully following the hospital policy. It was established that Mr. B had not been hooked to the respiratory monitor nor hooked to the continuous ECG monitor, yet he was under sedation. The hospital policy under the sedation ("conscious sedation") policy that "patient remains on continuous B/P, ECG, and pulse oximeter throughout the procedure and until the patient meets specific discharge criteria" like being fully awake and having no N/V. Also, it was the responsibility of nurse J and the LPN on duty to attend to Mr. B's and to frequently visit his room until it was determined he is stable. Ensure that his oxygen supplemental and saturation was at the desired reading, the first time the alarm went on. Instead, she just reset the alarm and went out to prepare for the incoming respiratory emergency.

It can also be argued that the nurse got distracted in preparation for the incoming respiratory emergency. Although it is not neglecting, it would have been better for a nurse to be around Mr. B.

Improvement plan

An improvement plan is highly helpful, especially in reducing the risk and likelihood of sentinel events from reoccurring. The first step towards establishing an improvement plan is to first understand the problem to be addressed. According to mindToolsVideos, YouTube channel, "To establish a successful change process, one must first start by understanding why the change must take place" (MindToolsVideos, 2014). Based on Mr. B case and scenario, it is evident that the facility requires some improvements, especially in ER management.

The first improvement is having more nurses available in handling emergencies and have enough nurses who are monitoring already diagnosed patients. Another area that needs improvement is the frequent review of the various practice policies. For instance, if nurse J had reviewed the hospitals' conscious sedation policy, the resulting event of Mr. Bs brain damage could have been avoided. Thus, continuous monitoring of nurses and performance, frequent training, and revision on the various procedures and policies will significantly improve the welfare of the institution image, service quality, and general PR.

The hospital should have its own set of paramedic nurses to receive, diagnose, and monitor ER patients before they are fully admitted to the facility. This way, the issue of overworking or over engagement will reduce significantly.

B1. Change Theory

The change Theory of Nursing, developed by Kurt Lewin, is a three-phrase change model. This model is known as the unfreezing-change-refreeze model (Nursing Theory, 2016). The first phase of the theory (unfreezing) involves establishing the 'need' for the change to take place. Thus, the management gathers and prepares the necessary information that will be presented to the organization key stakeholders. It is advised that also including the successes and failure of the current policies be recognized and then point out areas of interest for change (MindToolsVideos, 2014). The 'unfreezing' process is very critical because of it the initial stage that attempts to answer the 'why' question. Thus it is very important of the introducers of change to ensure that communication, consultation, and participation of the key stakeholders is highly maintained (Cherry & Jacob, 2014).

Basing this stage on the scenario, the 'unfreezing' stage will result from the death of Mr. B, and the conducted RCA conducted from the STAT CODE. From the STAT CODE section, the patient had not been hooked to the ECG or respiratory monitor, which resulted in the difficulties in breathing. Another reason 'unfreezing' is the fact that the O2 saturation had alarmed when Mr. B's Oxygen saturation was at 85% but was ignored. Also, the ED lobby had become congested from the new incoming patients. Lastly, a policy had not been followed.

The second phase of the theory is the change stage, also referred to as the 'movement' or "moving to new level stage" (Nursing Theory, 2016). The stage is the actual processes of adapting to the introduced changes, policies, and or circumstance. Some of the activities that will be carried out at this stage will be ER staff and nurses reviewing the existing policies as often as possible, two-four times a month at least. Have a separate set of nurses and physicians that deal with paramedic emergencies before the patients are fully admitted to the hospital. This change will have a significant impact, especially in reducing workload and over engagement. Introduce volunteering learning classes were staff could revisit, certain procedures, policies, and practices in the different fields, familiarize oneself with policies, procedures, and any other knowledge-based training that will be necessary for quality services.

Lastly, the third phase is called the refreezing stage. The stage is also referred to as the reshaping stage (MindToolsVideos, 2014). This stage is more or less like the implementation stage. The management now monitors the level of engagement and the efforts being made by the stakeholders to appraise the new reform and changes. The hospital should start to conduct regular evaluations and also monitor the frequencies of the event occurrence. Punishment and or motivations to be implemented as a way of ensuring that the plan is fully adopted. That is, appreciate those who fully adopted the new change through rewards and motivations, while those who do not adhere be punished.

General Purpose of FMEA

Failure Modes and Effect Analysis is a proactive and systematic approach in identifying and evaluating the possibility of a process to fail and the relative impact that results from this failure (Institute for Healthcare Improvement, 2017). Healthcare centers need to conduct FMEA, especially in their RCA action plans to identify possible failures and the resulting consequences and thus establish other alternatives for addressing the same (CAMH, 2013).

C1. Steps of FMEA Process

To change a failed plan to have a positive outcome, the following activities and practices need to be implemented. 1) Appoint a team of experts in the related field determine was it the cause of the failure and suggest possible ways of addressing the failure. 2) Suggest possible amendments to the plan. Lastly, 3) if the failure keeps on recurring find an alternative. Basing the above information to the scenario, the first step will be to put together a team (nurse J, a policy manager, and expert research) who will gather the information with the objective of determining why Mr. B breathing problem was abrupt, what went wrong with the sedation procedure. After determining what went wrong, the team will assess the impact of the fail by determining the severity, the rate of occurrence, and how the failure could not have been detecting at the right time. Based on this information, the team will offer suggestions on what can be done to avoid another occurrence and whether or not to adapt a new action plan.

Intervention Testing

Conduct a quick survey on nurses to get a figure of how often sedation policy is used before a sedation procedure is performed. Conduct a quick survey of the number of nurses serving in the ER. Lastly, compare performance evaluation performance before and after the implementation of the intervention. Follow-up, on nurses performance, and patient satisfaction.

E1. Involving Professional Nurse in RCA and FMEA Processes

The professional nurse often plays the role of a leader in many ways. For instance, in promoting quality care, they lead by example. That is, delegating tasks to patients, such as taking medicine, exercises, and proper eating habits. They ensure that the patient is as comfortable and satisfied as possible.

In improving patient outcomes, nurses ensure that the patients are properly fed and hygienically taken care of. They are also responsible for ensuring the patient adheres to the doctor's prescriptions and advice. They maintain a favorable environment for the patient, especially in a situation where the patient cannot do anything, including helping themselves.

Professional nurses demonstrate great qualities of leadership in influencing quality improvement activities. In all healthcare facilities, nurses spend most of the time with patients; as a result, they establish a better understanding of the patient needs and that can easily suggest to the doctor what activity best works for the patient. For instance, if a patient has difficult...