Organizational Systems and Structural Leaderships: Root Cause Analysis

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Root cause analysis (RCA) is a tool that identifies and provides a solution to all the possible causes of an adverse incident (IHI, 2016). The purpose of RCA is to correct systematic challenges by looking back to all the factors behind a certain incident. It is therefore not effective in solving problems arising from deliberate negligence by the concerned parties (IHI, 2016). In any case, this tool is very useful is solving health-related adverse events. This is because the incidences are commonly caused by deep-rooted systemic failures. There are basically six chronological steps involved in conducting root cause analyses according to the Institute for Healthcare Improvement (IHI, 2016):

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Identify what happened

The circumstances surrounding the adverse event are lucidly elaborated in the correct order in which they occurred. Use of explanatory aids such as flowcharts and process maps can be used in this step.

Determine what should have happened

The task force involved in investigating the adverse event should be able to give an alternative account of how the event should have happened in an error-free way. They should develop a flowchart of events that can substitute the possible erroneous events identified in the original account.

Determine causes

The investigating taskforce should identify all direct and indirect factors that underlined the adverse event. This analysis step must be very thorough and exhaustive and if possible involve tools such as the fishbone diagram.

Develop causal statements

These statements basically illustrate the wider context of the identified issues in every process. They have three parts: the cause, the immediate effect and then the contribution to the final outcome.

Propose prevention solutions

These solutions will be applied proactively in the future to prevent a repeat occurrence. The proposed actions can touch on infrastructure changes, policy changes or new training methods. They can either be robust or weak solutions depending on their effectiveness in solving the identified problems.

Summary of the event

This is where the task force comes up with a simplified illustration of the adverse event and share it with the concerned staff to raise their awareness.

The scenario mentioned first shows an ignorance of the patients complete medical history. The doctor realized that the patient was indeed on Oxycodone after getting no response from Hydromorphone. It is only then that the doctor realized the potential drug interaction that was behind the non-response. This could have avoided the unnecessary high dose of both diazepam and hydromorphone as they sought to achieve sedation. The two drugs cause bradycardia and CNS depression as adverse effects, which are compounded at higher doses. The doctor was also not well conversant with the onset of action and duration of action of the recommended medications. Another causal factor was the lack of oxygen supplementation during the procedure while the patient was obviously under known CNS depressants. They had real potential to cause respiratory depression, especially at high dosages.

The other causal factor was not monitoring the patients ECG and respiratory rate after the procedure. This was contrary to the hospitals moderate sedation policy. The nurse also left the patient to be monitored by his son who obviously had no knowledge in interpreting the BP monitor results. He only alerted the nurse when the situation had deteriorated so badly to necessitate a resuscitation team. Had the nurse been present throughout the monitoring period, she would have caught the plummeting BP and oxygen saturation levels in time for less serious interventions. The contributing factors to this were the multiple tasks required of the nurse simultaneously.

Improvement Plan

The main improvement plan would be offering a training course for the moderation sedation module to all the health professionals in the hospital. Those who had prior training in the program will also be retrained. The understanding behind this is that the RCA showed that the health professionals did not apply skills learned in the module. This training program will mostly involve simulation training that incorporates practical experiences such as the analyzed scenario. Simulation training has proved to be the most effective method in preparing nurses for their work environments and also develop their skills (Crowe, Ewart, & Derma, 2018). This training will address the main systemic challenge of not adhering to the hospitals moderate sedation policy.

Another aspect of the plan is to ensure that the hospital has a clear communication strategy of informing the health professionals on duty about the availability of backup staff. Implementing this plan will attract resistance from the health professionals as they will view it as an indictment of their capabilities. The three phases of the Lewis change theory can be used to address this challenge, unfreezing, change and freezing (NURSINGTHEORY, 2016). Unfreezing will involve communicating the benefits of undertaking the training program again for the health professionals. The hospital management should outline clear benefits of doing things differently to both the professionals and the patients. This will mitigate the incidences of resistance which could derail the improvement plan. The next phase is a change where actual training of the module is conducted. The final step is freezing where the hospital emphasizes the application of the new skills learned as the normal behavior.

FMEA

Failure Modes and Effects Analysis tool are used to determine the processes which are part of the problem and their contribution to the severity of impact (IHI, Failure Modes and Effects Analysis, 2004). The name of the tool implies that it is mainly concerned with how an event occurred (modes) and its impact (effects). This tool can be used to analyze procedures for possible risks that must be prevented. It is also used to evaluate plans that are not yet in the implementation stage (IHI, Failure Modes and Effects Analysis, 2004). Seven steps are involved in the utilization of the FMEA (IHI, Failure Modes and Effects Analysis, 2004):

Determination of a plan that requires evaluation by the FMEA.

Recruitment of a diverse task force to carry out the analysis. This is because various types of professionals identify unique problems which are specific to their line of work.

The task force then comes up with all steps involved in the process under analysis. They must hold numerous meetings to cover the steps exhaustively. The steps should be simplified using flowcharts or another relevant tool.

Outlining the modes of failure together with all the underlying causes of each mode.

The task force then assigns risk priority numbers (RPNs) for each failure mode. Each mode is scored on three aspects: likelihood of occurrence, detection, and severity. The scores are on a scale of 1 to 10 corresponding with very unlikely and very likely. The RPN values help the task force to set priorities.

Result evaluation. The three scores are multiplied to give a final RPN score. The task force should then pick out the modes with the largest RPN values.

The RPNs are then used to inform on improvement processes. The impact of the changes is assessed by evaluating the change in RPN. A change of more than 50% shows that the improvements are successful.

Assessment of interventions

Evaluation of health professionals in simulation training of the moderate sedation module will help to assess how they prevent a repeat of the failure modes identified. They included: overmedication of pain and sedation medicine, ignorance of a patients full medication history, lack of patient monitoring, and non-adherence to the hospitals moderation sedation policy. The FMEA should also be used to determine the impact of the improvement plan by comparing the RPN values after implementation to those calculated before implementation. A significant change in the values will imply that the new plan is very effective.

Leadership in nursing

Professional nurses can portray leadership in their workplaces to achieve quality care and improved patient outcomes. The first demonstration is to ensure the availability of relevant staff in terms of skill and numbers (Sammer & James, 2011). This will ensure that all patients are adequately treated and monitored. The nurses can also emphasize on a relationally oriented leadership style which involves a personal connection between the nurses and patients (Sammer & James, 2011). This style improves patient satisfaction with the quality of care. It is also very effective in averting adverse events due to medication errors. Patient complications are also likely to be identified at an early stage when the nurses relate personally to their patients. Nurses can also be involved in the senior management to make strategic decisions that influence nursing activities (Rokstad, Vatne, & Engedal, 2013). they can advocate for better facilities for their work, workable schedules and better training for their safety and that of the patients. They should also participate in RCA and FMEA processes to demonstrate leadership (Sammer & James, 2011). In these processes, they can identify failure modes that are unique to the nursing profession such as administering wrong medication and also provide solutions for the same. They can also get feedback from other nurses when assigning RPN values to specific failure modes hence offer valuable input to the RCA and FMEA teams.

References

Crowe, S., Ewart, L., & Derma, S. (2018). The impact of simulation based education on nursing confidence, knowledge and patient outcomes on general medicine units. Nurse Education in Practice, 70-75.

IHI. (2004, June 15). Failure Modes and Effects Analysis. Retrieved from Institute for Healthcare Improvement: www.ihi.org

IHI. (2016, April 15). Patient Safety 104: Root Cause and Systems Analysis. Retrieved from Institute for Healthcare Improvement: www.ihi.org/

NURSINGTHEORY. (2016, May 10). Lewin's Change Theory. Retrieved from nursing theory.org: www.nursing-theory.org/theories-and-models/

Rokstad, A., Vatne, S., & Engedal, K. (2013). The role of leadership in the implementation of person-centered care using Dementia Care Mapping: a study in three nursing homes. Journal of Nursing Management, 15-26.

Sammer, C., & James, B. (2011). Patient Safety Culture: The Nursing Unit Leader's Role. The Online Journal of Issues in Nursing, 1.

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