Root Cause Analysis and Failure Mode and Effects Analysis in Healthcare, Exams of Sociology

Download Root Cause Analysis and Failure Mode and Effects Analysis in Healthcare and more Exams Sociology in PDF only on Docsity! 1 Updated: 2/1/19 Organizational Systems and Quality Leadership SAT Task 2 Best Version Update Root Cause Analysis The general purpose of a root cause analysis (RCA) is to examine an unfavorable outcome to an incident using a standardized process. During a root cause analysis, the problem and how systems or processes work and why is identified. After the reason the incident occurred is identified, that information is used to find a solution to the main reason such problems exist. (Systems Thinking: What, Why, When, Where, and How? 2016) RCA Steps Step one: Identify the problem In this step the problem is identified usually after an event with unfavorable outcomes or complaints. A team is then formed to go through the remaining steps of a root cause analysis. In this step the team needs to clarify the problem as objectively as possible and remove blame from 2 Updated: 2/1/19 the equation. (Patient Safety 104: Root Cause and Systems Analysis) Step two: Determine what should have happened The problem has been identified and now the how did the problem occur is examined in this step by looking at the system or processes to determine was the process followed or is there an error in the way the system works. (Patient Safety 104: Root Cause and Systems Analysis) Step three: Determine the main reason or causes this happened The team examines the steps and missteps that led to the incident occurring, anything the most obvious to deep diving into the things that added to the issue. According to subject matter experts the recommendation is made to “ask why five times” to derive the main reason for the incident. (Patient Safety 104: Root Cause and Systems Analysis) 5 Updated: 2/1/19 follow when change is evitable. These guidelines included that changes should only be made with good reasons, always planned and followed through, should never be sprung onto the persons involved and those involved should be a part of the developing the change. There can be many reasons for change such as processes or leadership but in any event Lewin’s change theory can be applied. (Cherry, pp304) Lewin’s change theory has three phases. Phase one called the “unfreezing stage,” in which the representative for change needs to identify the situation and then create awareness around the necessity to improve. The next phase called the “moving stage,” is where the representative for change sets the what, why and how for the change to be implemented. It is their responsibility from start to finish to see it through including setting “goals and objectives,” selecting team involved and evaluating the change after implemented and adjust accordingly. Lastly, third phase “refreezing stage,” The representative incorporates the change into the company so that it becomes standard practice. (Cherry, pp304). In development of the proposed improvement process of pharmacy hard stopping medications pulled within 15 minutes from last withdrawal and standardized staffing grid I would first create awareness around the need to change how things are currently being done, then once I have staff’s buy in on the necessity of change, I would be involved from start to finish by selecting a team to work on the change, set timeframes and end results, evaluating what is needed to make the change. Finally, the team and I would bring the change to the nursing directors of the ER and get the change added to the daily operations and continue to monitor the change and supporting the staff with any issues in the change becoming current practice. 6 Updated: 2/1/19 General Purpose of FMEA The general purpose of the failure mode and effects analysis (FEMA) process is a method to recognize potential failures that may emerge. Healthcare systems have begun using this process to enrich the quality of care and minimize damaging mistakes (Failure modes and effects analysis tools, n.d.). Teams assess, evaluate, and document information using the following from the FMEA tool: Steps in the process, what failure could occur, why the failure happened, and what the possible outcome from the failure happening. Steps of FMEA Process Step One: Select a process to evaluate with FMEA Decide what process you want to investigate for improvement. Step Two: Recruit a multidisciplinary team Develop a team made up of staff from different departments in which the process will affect in order to have a collaborated effort to improve the process. Step Three: Have the team list all the steps in the process The team will then note from start to finish the phases taken in the process. Step Four: Fill out the FMEA table with the team Together the team fills out the FMEA table to put into perspective what could go wrong and why it would happen and what the likeliness of this occurring would be and the severity. Step Five: Use Risk Priortiy Numbers (RPN) to plan improvements The team assigns numbers (RPNs) based on a scale to the failures listed and the ones with the highest numbers will then be candidate for the most improvement within the process. Lastly the team will continue to use the RPN tool to further monitor the improvements and need for adjustments. (Failure Modes and Effects Analysis (FMEA) Tool: IHI) 7 Updated: 2/1/19 List 4 steps in your Improvement Plan Process * List 1 Failure Mode per step Likelihood of Occurrence (1–10) Likelihood of Detection (1–10) Severit y (1– 10) Risk Priority Number (RPN) Example: On-call staff must clock in within 30 minutes of being notified. On-call staff forget to clock in when arriving to the unit. 4 5 2 40 1. MD will order the medication for sedation Look a like medications may be ordered instead 5 5 7 175 2. Pharmacy will review the medication and approve or deny Will not look back at previously dosed time to see if within administration timeframes 4 7 5 140 3. The nurse will inspect medications and dosage before administration Didn’t review administering instructions per pharmacy 4 5 5 100 4.Computer will have a witness sign off on medication Will not scan medication and have witness, in order to save time. 8 5 8 320 10 Updated: 2/1/19 started. A professional nurse can demonstrate leadership by growing the unit staff and having a nurse practice council which influences quality improvement projects within the unit and sometimes entire hospital. A professional nurse can demonstrate leadership by being an overall resource and working along side the staff, delegation and supporting for a better work environment and patient satisfaction. All of these qualities represent a more transformational type of leader and studies do show a higher sense of satisfaction amongst staff. (Cherry, S.pp 291) Involving Professional Nurse in RCA and FMEA Processes The involvement of the professional nurse in the RCA process shows leadership qualities as a nurse who is leading a team to make an observation about an incident gone wrong and instead of blaming staff helping guide staff and all affected departments to finding a solution. The professional keeps everyone on track and offers input but ultimately has the team complete the work and acts as a resource from start to finish with continuous monitoring. The involvement of the professional nurse during the FMEA process demonstrates leadership qualities such as ability to be honest and forthcoming with a break in a process. The professional nurse as shows leadership by ability to select a team and encourage them to complete the goals set in the FMEA process. The professional nurse’s ability to bring different departments together to work on improving quality, patient outcomes and care is a true test of leadership. 11 Updated: 2/1/19 References Advanced Solutions International, I. (n.d.). Retrieved December 02, 2020, from https://education.ihi.org/topclass/topclass.do?CnTxT-24237493-contentSetup- tc_student_id=24237493-item Cherry, Susan Jacob, B. Contemporary Nursing. Elsevier Health Sciences (US) in pp. 290- 304. [Western Governors University]. Failure Modes and Effects Analysis (FMEA) Tool: IHI. (n.d.). Retrieved December 02, 2020, from http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx Patient Safety 104: Root Cause and Systems Analysis. (n.d.). Retrieved December 01, 2020, from https://srm--c.na127.content.force.com/servlet/fileField?id=0BE0c000000Tv9N Systems Thinking: What, Why, When, Where, and How? (2016, August 16). Retrieved November 26, 2020, from https://thesystemsthinker.com/systems-thinking-what-why- when-where-and-how/