A Sentinel Event at the Emergency Department

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Table of Contents

Root Cause Analysis
Application of RCA and Factors
Process Improvement Plan
Lewin’s Change Theory
Failure Mode and Effects Analysis
Intervention Testing
Leadership
Nurses in RCA and FMEA
References

Healthcare providers occasionally encounter situations that do not result in positive patient outcomes. The provided case study (CS) describes a sentinel event of Mr. B, a 67 years old man, who is delivered at the ED (Emergency Department) of a rural hospital after experiencing a fall. The medical team, which consists of physician T, RN J, an LNP, and a secretary, does not manage to save the patient’s life. The case requires conducting a root cause analysis alongside a failure mode and effects analysis to identify mistakes and propose ways to prevent possible errors.

Root Cause Analysis

To perform RCA (Root Cause Analysis), members of a healthcare team (HT) are expected to meet and assess the issue. The general purpose of conducting RCA is to identify system vulnerabilities to eliminate and mitigate them and understand the reasons behind errors (Institute for Healthcare Improvement [IHI], n.d.a). RCAs are retrospective and typically consist of six steps (Institute for Healthcare Improvement [IHI], n.d.b). First, HT must carefully and completely describe what happened in the order it occurred (IHI, n.d.b). Second, HT has to discuss and resolve what should have happened in ideal conditions (IHI, n.d.b). Third, HT must determine factors that contributed to the event, such as considering patient characteristics, work environment, task elements, team facets, individual staff members, institutional context, and organizational and management factors (IHI, n.d.b). Fourth, HT needs to develop casual statements linking causes to effects and then back to the central occurrence that initiated RCA (IHI, n.d.b). Accordingly, the first four steps of RCA concentrate on analyzing the situation and distinguishing the primary errors.

Furthermore, the final two stages of RCA focus on implementing improvements. The fifth step asks HT to create a list of recommendations to prevent the event from happening again (IHI, n.d.b). For instance, changes can aim at updating or enhancing software, simplifying processes, or developing new policies (IHI, n.d.b). The final phase of RCA involves writing a summary and sharing it while engaging the key players to help accomplish the improvements (IHI, n.d.b). Overall, the RCA procedure is meant to learn from mistakes that led to undesirable situations and execute positive modifications.

Application of RCA and Factors

The RCA process can be applied to the provided CS about Mr. B and the actions taken by the staff members. Notably, RCA is not meant to identify someone to blame but rather concentrates on system circumstances (IHI, n.d.b). Therefore, the individuals involved in the CS and mentioned above will have to meet and discuss what occurred. The HT will need to discuss what should have happened, such as that Mr. B’s vitals should not have dropped. Upon assessing the situation, the HT will have to determine what induced the CS’s outcomes.

In the third step of RCA, the HT will identify the causative and contributing factors that guided the event’s occurrence. The former type of influence refers to direct reasons, whereas the latter kind represents forces that are indirect in nature (IHI, n.d.b). Consequently, the primary contributing factors are insufficient staffing and patient load. The employees at the site were occupied caring for an emergency patient in acute respiratory distress. The circumstance added to the HT’s busyness as they were already in the process of discharging two other individuals, aside from Mr. B. Meanwhile, the ED lobby was filled with more people who needed medical assistance, and, although the additional staff was available, the CS does not mention that more specialists were called. For instance, when Mr. B’s saturation was at 85%, it seems that no specialist was available to timely review the O2 alarm. Accordingly, high work overload on the day of the incident contributed to aspects that forced the event’s outcome.

Furthermore, causative factors are interconnected to the above-described characteristics. The CS states that the hospital where Mr. B was originally treated had a sedation policy, which mandates that patients must remain on continuous B/P, ECG, and pulse oximeter. Nonetheless, after his hip was cared for, Mr. B’s ECG and respirations were left unmonitored. One can assume that such a violation of the medical facility’s policy may have been caused due to busyness of the staff members who were called to attend to the emergency patient. Moreover, the hospital requires practitioners to undergo a training module on drug selection and dose ranges to perform moderate sedation. Nurse J had completed the instruction and was the one administering medications to MR. B but did so following the orders of Dr. T. However, it is unclear whether the physician has finished the module and if the training provided accurate information on dosages of diazepam and hydromorphone for older adults who take oxycodone and have various health conditions. Consequently, causative factors are likely to be insufficient employee instruction and a lack of time to follow guidelines.

Process Improvement Plan

An important step of RCA is advancing procedures to prevent the reoccurrence of an undesirable event. The main aspects that led to the CS’s outcome suggest that a process improvement plan (PIP) should focus on educating staff and changing procedures (IHI, n.d.b). Because it is not clear if Dr. T has completed the module training, the hospital should ensure that all employees, whether they order or perform sedation, understand the usage of medications, especially combinations of drugs. Furthermore, the medical facility should modify the requirement to continuously monitor patients’ vital indexes to make it easier for workers to assess that all equipment operates properly. Finally, although Nurse J transmitted information about Mr. B to Dr. T, it seems that the hospital has communication troubles because the HT did not invite additional staff when witnessing a high patient load. Therefore, the establishment needs to encourage professionals to interact with each other before a crisis occurs. The recommendations can decrease the likelihood of a reoccurrence of the event by assuring that employees know how to order and administer sedation properly, double-check equipment, and ask each other for help.

Lewin’s Change Theory

The proposed PIP can be assessed under Lewin’s change theory (LCT). The approach must consider the human side of change because influential transformations are likely to generate people issues, with some individuals being uncertain and resistant (Deborah, 2018). Therefore, the hospital should begin by creating a methodology that handles modifications appropriate to the facility’s needs (Deborah, 2018). The first step of LCT focuses on the organization’s readiness to accept the anticipated change and shift employees’ values, beliefs, and conduct (Deborah, 2018). The stage can be applied to PIP by encouraging the hospital’s staff to reflect on Mr. B’s demise and comprehend the necessity for transformations. The second phase concentrates on looking for better ways of operation and can be utilized to demonstrate how each individual will benefit from an updated policy of additional training (Deborah, 2018). The final step aims at incorporating new standards and can be used to design such methods to sustain transformations as official procedures and reliable job descriptions (Deborah, 2018). Accordingly, Lewin’s change theory can be applied to the suggested PIP by preparing and explaining to employees the need for changes.

Failure Mode and Effects Analysis

Another way to assess and control the possibility of errors is by utilizing failure mode and effects analysis (FMEA). The general purpose of FMEA is to prevent mistakes by examining processes for potential losses and correcting them proactively instead of letting errors occur (Institute for Healthcare Improvement [IHI], n.d.c). FMEA involves five main steps, and the first one is selecting a process to be evaluated, but it should not have too many sub-processes (IHI, n.d.c). The second phase concentrates on recruiting a multidisciplinary team (MT), which should include everyone involved in the process to discuss all details (IHI, n.d.c). FMEA’s third stage requires the MT to list all of the steps of the process, while the fourth phase focuses on filling out a table concerning such aspects as failure mode and causes (IHI, n.d.c). The final stage asks to plan improvement efforts using risk profile numbers, which are derived from multiplying three numeric scores from the FMEA table (IHI, n.d.c). Overall, each step of FMEA is necessary to identify and prevent failures before they happen.

Table 1 presents the application of FMEa to the primary steps of the proposed earlier PIP. For instance, the failure mode mandating sedation education for all practitioners assumes that the training may not consider how certain sedation corresponds with other drugs taken by patients. The likelihood of occurrence is 5 out of 10 as each patient has a unique health history. The possibility of detection is 2 because it is expected that the practitioners will recognize if a specific combination was not covered in training. However, the severity is 5 since if the failure does occur, employees are anticipated to seek more information but may not have enough time to do so. Accordingly, a similar logic is applied to the scores of the PIP’s other parts.

Table 1. FMEA for the proposed PIP

Steps in the Process	Failure Mode	Likelihood of Occurrence (1-10)	Likelihood of Detection (1-10)	Severity (1-10)
Sedation training: Education on the correct usage of drugs and their combinations for all practitioners, whether they order or perform sedation.	Training may not consider how a sedative reacts to a specific drug taken by a patient.	5	2	5
Modifying sedation policy: Establishing double-checks of equipment monitoring patients’ vital parameters.	The employee appointed to do double-checks may not have enough time to assess all monitors.	8	3	10
Enhanced communication: Ask for additional staff when the number of patients per shift reaches a certain point.	Staffing on a particular day may not timely call for backup employees.	2	1	4

Intervention Testing

Interventions from the offered PIP need to concentrate on regularly monitoring the effectiveness of each action. Because the PIP is a continuation of RCA, the healthcare team involved in RCA should oversee the usefulness of the plan. RCA has to have support from clinical and administrative leaders and may sometimes include patients and their families (IHI, n.d.b). Therefore, the hospital’s leadership, patients, and HT should identify individuals who would review interventions’ implementation. For instance, to test the recommendation of simplifying the sedation policy to ensure that equipment monitoring patients’ vital indexes, the medical facility could appoint an employee responsible for redundancy and double-checks (IHI, n.d.b). Such an individual could be a nurse or a secretary who would periodically examine monitors and assess what may have caused stops. Upon identifying any errors and reasons, the employee would help HT in determining ways to enhance the intervention. Overall, to test the suggested PIP’s effectiveness, the hospital should have individuals who would establish expected results for each recommendation and measure if they correspond with factual conditions.

Leadership

Nurses are crucial partakers of providing care, and nurse leaders (NLs) can affect several areas of work in a medical facility. First, nurses can demonstrate leadership in promoting quality care by learning and utilizing such skills and behaviors as strategic thinking, confidence, motivation of self and others, and effective communication (Page et al., 2021). The listed competencies can provide NLs with the direction and support needed to guide patient care delivery (Page et al., 2021). Second, nurses can show leadership in improving patient outcomes by ensuring that appropriate staffing and resources are available to attend adequately to those seeking medical assistance (Page et al., 2021). Third, nurses can exhibit leadership in influencing quality improvement activities by removing structural and relational barriers to interventions (Chen et al., 2020). Accordingly, a professional nurse can completely demonstrate leadership by developing specific qualities and participating in guiding care delivery, securing necessary assets, and overcoming obstacles toward advancement.

Nurses in RCA and FMEA

Nurses can display their leadership abilities by being involved in RCA and FMEA. Both processes highlight the significance of change to prevent errors, and NLs can facilitate the acceptance of modifications (IHI, n.d.b). As participants of RCA and FMEA, NLs can challenge the status quo and address issues regarding quality and patient safety (Page et al., 2021). Moreover, NLs can exhibit leadership in FMEA and RCA by assessing microsystems, mapping processes, and determining opportunities to improve (Noles et al., 2019). Consequently, a professional nurse’s involvement in the RCA and FMEA processes can demonstrate leadership qualities by driving changes needed to advance procedures and decrease the possibility of mistakes.

References

Chen, H., Feng, H., Liao, L., Wu, X., Zhao, Y., Hu, M., Li, H., Hu, H., & Yang, X. (2020). Evaluation of quality improvement intervention with nurse training in nursing homes: A systematic review. Journal of Clinical Nursing, 29(15-16), 1-13.

Deborah, O. K. (2018). Lewin’s theory of change: Applicability of its principles in a contemporary organization. Journal of Strategic Management, 2(5), 1-11.

Institute for Healthcare Improvement. (n.d.a). RCA2: Improving root cause analyses and actions to prevent harm. HIH. Web.

Institute for Healthcare Improvement. (n.d.b). RCA2: Patient safety 104: Root cause and systems analysis. HIH. Web.

Institute for Healthcare Improvement. (n.d.c). QI essentials toolkit: Failure modes and effects analysis (FMEA). HIH. Web.

Noles, K., Barber, R., James, D., & Wingo, N. (2019). Driving innovation in health care: Clinical nurse leader role. Journal of Nursing Care Quality, 34(4), 307-311.

Page, A., Halcomb, E., & Sim, J. (2021). The impact of nurse leadership education on clinical practice: An integrative review. Journal of Nursing Management, 29(6), 1-13.

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