Root Cause Analysis and Failure Modes and Effects Analysis in Healthcare, Thesis of Marketing Research

Download Root Cause Analysis and Failure Modes and Effects Analysis in Healthcare and more Thesis Marketing Research in PDF only on Docsity! Running head: Organizational Systems Task 2 1 C489 Organizational Systems and Quality Leadership Task 2 Western Governors University Organizational Systems and Quality Leadership Task 2 A. Root Cause Analysis When the Institute of Medicine (IOM) published findings on medical errors that caused patient harm, it brought forth a focus on the identification and recommended improvements in six dimensions of healthcare in the U.S. One of these dimensions for improvement is patient safety. Patient safety is paramount in healthcare. The IOM reported that medical errors, near misses and adverse events continue to occur at an astonishing rate. The Institute for Healthcare Improvement (IHI, 2019c) defines a root cause as a “latent vulnerability in a system that allows an incident to occur.” A root cause analysis (RCA) is a process that looks to understand and respond to root causes, to prevent harm. It is a systematic approach to understanding multiple contributing causes that lead to an adverse event to occur and taking actionable measures that will yield effective, sustainable results. A1. RCA Steps According to the IHI, an RCA team is composed of four to six people to utilize a six-step process to conduct a root cause analysis. The members of the team should not include those involved in the event. Individuals involved in the event should be interviewed for information. Step one is identifying what happened. The collecting of information to accurately and completely describe the adverse event that occurred. Step two is to determine what should have Running head: Organizational Systems Task 2 2 happened. During this step, the team determines that given ideal conditions, what should have happened. Step three is to determine the causes. Determining the factors that contributed to the adverse event. Often times, it is not just one root cause but multiple factors that contribute to an error occurring. Step four is to develop causal statements. A causal statement links the cause that was identified in step 3 to its effects and then back to the main event that prompted the root cause analysis. Step five is to generate recommended actions. These actions are changes that the root cause analysis team reasons will help prevent the adverse event from happening in the future. Finally, step six is to write a summation and communicate it. A2. Causative and Contributing Factors The hospital will need to put together a team in order to conduct a root cause analysis. Members of the team will involve four to six individuals of various disciplines. Once the team is assembled, they will embark on the six steps of the RCA. The first step is to identify what happened with Mr. B. Mr. B. sustained a ground level fall causing him to be brought to the hospital emergency department by his son and neighbor with complaints of severe pain in his left hip and leg. After admission to the emergency department, it was determined that he needed a conscious sedation procedure for the physician to perform a closed hip reduction. Due to not adhering to the moderate sedation protocol, lack of staffing, lack of monitoring of Mr. B. during and post procedure, and not addressing his past medical history, Mr. B. went into cardiac arrest. The hospital transferred him to a different facility for advanced care and unfortunately, Mr. B. passed away after being removed from life support. The second step of the process is to determine what should have happened under ideal circumstances. Upon completion of Nurse J’s assessment of the patient, the information would Running head: Organizational Systems Task 2 5 participants to help drive the next steps in improvement. This can be accomplished in multiple ways, which include staff meetings, emails, continuing education modules, and skills day. B. Improvement Plan The improvement plan should address the factors that contributed to the events occurrence. First utilizing a standardized checklist for a patient undergoing a moderate sedation procedure should be used. The first area the checklist would address is a thorough review of the patient’s past medical history and current medications, especially the use of narcotics and opioids. Reviewing the use of narcotics and opioids can compound the effect medications have on the patient’s respiratory drive and to cause hypotension. The second area of the checklist would include appropriate doses of sedation medication given the patient’s age and condition. The checklist would also ensure all the appropriate equipment to perform the procedure and to monitor the patient during and post procedure. This would also cue the staff to ensure the proper staff to patient ratio is available. The checklist would also contain a flowsheet to record necessary information regarding conscious sedation. Documentation would include noting medications administered, amount given, route, and documenting the patient’s vital signs at specified increments. Each aspect of this checklist would ensure patient safety and decrease the likelihood for any error to occur. B1. Change Theory Change is an inevitable part of healthcare. In Lewin’s Change Theory, there are three stages: unfreezing, moving, and freezing. Effective change occurs in these three stages. The unfreezing stage “promotes problem identification and encourages the awareness of the need for change. People must believe that improvement is possible before they are willing to consider change (Cherry & Jacob, 2017).” A department staff meeting should be conducted to Running head: Organizational Systems Task 2 6 make all aware of the event that occurred to help them understand why a change is necessary and given education how the change will occur. This gives the staff an opportunity to adapt to the idea of change. The findings of the root cause analysis would be shared with the staff in the emergency department based on the event that occurred with Mr. B. The improvement plan would be shared with the staff and the standardized checklist for moderate sedation procedures. Communicating this information would allow the staff to offer feedback, providing opportunities for suggestions, and seek opportunities for clarification. The moving stage “clarifies the need to change, explores alternatives, defines goals and objectives, plans the change, and implements the change plan (Cherry & Jacob, 2017).” The staff would be taught about the different components of the checklist and how to properly execute each component. Staff would be given hands on experience and have available resources in case there is a need for clarification or concerns to be addressed. The refreezing stage integrates the change into the organization so that it becomes a standardized operating procedure. The goal of the refreezing stage is to prevent old behaviors from resurfacing. The standardized checklist for conscious/moderate sedation will become part of normal policy and procedure. The checklist is to be utilized on every occurrence in which a conscious/moderate sedation procedure is to occur. Utilizing this checklist will allow the hospital to monitor and track data to ensure that the checklist is successful in promoting patient safety. It is important for resources to continue to be readily available to staff. Continuing education are key to successful change. C. General Purpose of FMEA The Institute of Healthcare Improvement outlines a process that looks to prevent failures from occurring. Failure modes and effects analysis (FMEA) is a proactive and systematic Running head: Organizational Systems Task 2 7 process of looking at potential issues that arise and developing a plan to prevent the error from occurring. The FMEA process is an approach made by a multi-disciplinary team with each of the team members having knowledge of how things work with the process (IHI, 2019a). C1. Steps of FMEA Process The FMEA process involves five steps. The first step is to select a process that will be evaluated with FMEA. It is stated that the FMEA process works best with processes that do not have too many sub-processes. The second step is assembling a multidisciplinary team. Involvement of a team member who is involved at any point of the process being evaluated is highly recommended. The third step is for the team to list all the steps of the process. An ordered list of the steps involved in the process can be utilized. The fourth step is for the team to list failure modes and causes. This step involves listing anything that could potentially go wrong, including minor and rare problems and identifying possible causes. The fifth step is using risk profile numbers to plan improvement efforts. For each failure mode, a numeric value is assigned, also called the risk profile number, for the likelihood of occurrence, likelihood of detection and severity. A higher risk profile number guides the team to prioritize their efforts. C2. FMEA Table See attached document. D. Intervention Testing To test the interventions from the process improvement plan, using the approach known as Plan-Do-Study-Act (PDSA) allows the improvement plan to be tested on a small scale prior to deploying the improvement plan on a larger scale. First, the improvement plan would recruit the aid of one RN and one physician to test the standardized conscious moderate sedation checklist within the emergency department. The checklist would initially address a thorough assessment