Root Cause Analysis (RCA) is a tool designed to help identify not only what and how an event occurred, but also why it happened. We can see from this scenario that the root cause is the lack of oxygen given to this patient, however it is not the only cause. A string of events lead to this patients demise. The first and most important cause was that hospital policy was overlooked. In the scenario it stated. Root Cause Analysis (RCA) is a tool designed to help identify not only what and how an event occurred, but also why it happened. We can see from this scenario that the root cause is the lack of oxygen given to this patient, however it is not the only cause. A string of events lead to this patients demise. The first and most important cause was that hospital policy was overlooked. In the scenario it stated “A moderate sedation/analgesia (“conscious sedation”) policy 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).”
The trained nurse had the equipment to insure that this policy was followed, however failed to perform her duties as required by this policy. The second event is that the LPN reset the alarm and made no effort to provide an intervention for the alarm. The LPN did not inform the RN of the O2 Saturation level. The LPN Was not trained properly. The third event was that there was not enough staff called in for the level of acuity that these patients had. The administration should have been made aware of the emergency coming in and called in more staff to accommodate the staffing need. The errors or hazards in care in the scenario were that the RN failed to follow hospital policy to continuous monitor the patient. LPN was not properly trained to handle patients with a higher acuity. LPN failed to report and respond to the alarm. It would be helpful if the parties involved with this event come together and discuss on what failed and how they can improve the system.
To decrease the likelihood of this happening again the data collected from the RCA needs to be presented and a plan needs to be implemented so that all the staff can know what to do if this situation occurs in the future. Implementing a plan where all the parties are involved will insure that policy that is implemented will be followed through and a since of teamwork and collaboration will be felt. Lewin’s change model talks about people that are frozen in their idea of how certain processes should work, and need to be unfrozen in their process in order to make a change. In the scenario, the staff may be stuck in a process of how they perform their job. When things in the ER got busy, The nurse may have felt that since she has experience and is qualified she could handle things in the ER with just the help of the LPN. If this Nurse was not frozen in her old ways she would have realized that knowing when to call for help early enough is a nursing key behavior.
Sometimes being stuck in your old ways is not what is best for the patient or yourself. If the future with change this Nurse has the potential to be a good advocate for other nurses and staff. She will be helpful in supporting change for the better of the patient. Lewin’s second model talks about what needs to be changed in a situation. In the scenario, the process of how moderate sedation is performed and followed up for each and every patient in any department needs to be changed. In order to make a change, staff needs to become involved and understand why this change will benefit the patient and the nursing staff. In order to make a change and have it successful the staff will need intrinsic motivators. According to Lewin’s change theory the staff will need to first, be open to the idea of this change and second, see how it can benefit the quality of care given to patients.
Updating the moderate sedation policy to include a one on one “qualified” staff member to stay with the patient after sedation at all times until discharge criteria is met. Staff education, annual education and possibly mock sedation scenerio’s could help the staff learn in a “real life” situation what could go wrong and what could be done better. When the change has been introduced. Trial and errors are started and perfected and staff starts to use these changes in practice. It has a possibility to become normal to them and then the “refreezing” process can begin. Lewin’s refreezing process is referred to as, once new change is in practice the staff will then start to implement that changed process in everyday procedure, cause a refreezing process of new and improved procedure. After, Nurse J and the other staff members in the ER and everywhere else in the hospital, practice and start applying these new changes into their everyday routine after several weeks, it will become second nature to them! (“Change theory,” February)
Failure modes and effects analysis (FMEA) identifies all possible failures in a service rendered. “Failure modes” means the ways, or modes, in which something might fail. Failures are any errors or defects, especially ones that affect the customer, and can be potential or actual. “Effects analysis” refers to studying the consequence of those failures. (The Quality Toolbox.2004) The interdisciplinary team that should be included in the RCA and FMEA are everyone involved like all doctors, RN’s, LPN, administrators, and the joint commission. We would start by developing steps to assess risks of failure to patients in the process that is being used. The pre-steps needed to implement FMEA is that the interdisciplinary team needs to be in agreement with how many steps and the steps that accurately describe the process. For each Failure mode the team needs to assign a risk priority number (RPN), this is used to detect the likelihood of occurrence, detection and severity.
For every failure mode identified, the team should answer the following questions and assign the appropriate score. (the team should do this as a group and have consensus on all values assigned) 1) How likely is it that this failure mode will occur? 2)Assign a score between 1 and 10, with 1 meaning “very unlikely to occur” and 10 meaning “very likely to occur.” And 3) How likely will the error be caught before causing harm to the patient. (IHI.pdf) The first step in FMEA is to analysis how likely is it that this failure mode will occur and its severity of affect on the patient. To do this the hospital would assign a severity number to the process step that they are testing. The FMEA would have number 1 through 10. 1 would mean no harm would be done to the patient, 5 would be moderate harm to the patient and 9 or 10 would mean that the severity would be very bad with the worst possible outcome for the patient.
Like in the case scenario if the process step they chose was: with no equipment for monitoring of a patient after sedation and without staff present or staff present and all equipment was present. The process failure mode was that the patient stops breathing and no one or no equipment was present. The number value for this scenario would then be assigned the highest number because of the high likelihood that it would have the worst outcome for the patient. The second step in the FMEA is to analyze how often the error or potential problem is likely to happen in the process. The occurrence scale also has a numeric value of 1 to 10. 1 would be that the problem could occur in under 0.01 to every 1,000 people, 5 would represent about 5 people to every 1,000 people and 10 would have the highest occurrence of over 100 people to every 1,000 people, which would make it very likely that the event will occur.
The hospital staff would than take their process step of not monitoring a patient after sedation and rate the occurrence of the process at how likely the event would happen. The hospital then can look at data from other hospitals that did not monitor patients after sedation to see the likelihood that they stop breathing to rate the number. The third and last step is how likely the error or problem can be caught before reaching the patient and on what degree of harm it can cause to the patient. The same principle applies to the detection scale of a scale of 1 to 10. All of the numerical scores would then be multiplied together: Severity x Occurrence x Detection = Score.
A score over 100 would prompt the hospital to look into the problem more closely and anything below that number they may want to take off their agenda and focus on the more dangerous outcomes for the patients. (Forrest, 2010) The key role nurses would play in improving the quality of care in this situation. Are to implement a plan of action. They can sponsor classes for other staff to get educated. They can attend drills to rehearse different scenarios to be prepared for other events. Having nursing staff advocate for the change will also help the other staff follow by example when changes are made, especially if they know the reason is to help prevent harm to patients in their care. Nurses with the right tools, guidelines and policies are able to make sure that the care is the best quality for their patients.
Change theory. (January, 2014, 02). Retrieved February 20, 2015, from http://wgu.hosted.panopto.com/Panopto/Pages/Viewer.aspx?id=e348f20b-e819-43e4-abcaf191f99bc
Failure Modes and Effects Analysis (FMEA) Tool. (n.d.). Retrieved February 20, 2015, from http://www.ihi.org/resources/FailureModesandEffectsAnalysisFMEATool_IHI.pdf
Forrest, G. (2010, December 31). Quick guide to failure mode and effects analysis. Retrieved February 20, 2015, from http://www.isixsigma.com/tools-templates/fmea/quick-guide-failure-mode-and-effects-analysis/
IHI Institution for Healthcare Improvement. (n.d.). Lesson 5 testing changes (Pages 1-2). Retrieved from http://www.ihi.org/education/ihiopenschool/Pages/default.aspx Policy name: Root cause analysis. (n.d.). Retrieved from
Nancy R. Teague The Quality toolbox, 2nd edition, ASQ Quality Press, 2004, pages 236-240.