Importance of Analyzing Undesired Outcomes in a Healthcare Setting

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Table of Contents

Introduction
Root Cause Analysis
Improvement Plan
FMEA
Interventions Testing
Leadership
Conclusion
References

Introduction

The effectiveness of the healthcare sector depends on the aligned work of teams and their readiness to respond to critical situations. Unfortunately, it is impossible to avoid sentinel events and undesired outcomes. For this reason, it is necessary to analyze the root causes for the emergence of accidents and offer measures to eliminate them. The application of such tools as root cause analysis (RCA) and failure mode and effects analysis (FMEA), and change models and theories might help to acquire an improved vision of a particular scenario and offer steps to avoid its repetition in the future. These frameworks serve as potent approaches to enhancing the teams’ work within the healthcare sector. The proposed scenario can be analyzed by using RCA and FMEA to outline the causes for poor outcomes and offer possible improvement strategies.

Root Cause Analysis

The analysis of primary factors contributing to the emergence of undesired situations can be performed by using RCA analysis. It is a systematic approach to determine the causes of an adverse event and outline system flaws that can be corrected to avoid the same mistakes in the future (Institute for Healthcare Improvement, n.d.). In such a way, its central purpose is the investigation of the aspects promoting poor results and their elimination. It consists of the six steps:

Step 1. Identification of what happened. The team should describe the event in detail.
Step 2. Determination of what should have happened. The team should outline ideal outcomes.
Step 3. Determination of causes. The team should analyze direct causes and contributory factors influencing the situation.
Step 4. Development of casual statements. The cause should be linked to its effects.
Step 5. Recommendations. Offer recommendations to avoid the reoccurrence of the same mistakes.
Step 6. Summary. Create a summary that can be used for future improvement (Institute for Healthcare Improvement, n.d.).

Applying the RCA analysis to the provided case, it is possible to outline the causative and contributing factors that resulted in the emergence of undesired outcomes:

Step 1. Mr. B had a brain death and died.
Step 2. Mr. B should have had pain relief and improvement of this state.
Step 3. Direct causes: Causative factor: the amount of sedation. The sedation the patient received resulted in a cardiopulmonary arrest. Contributory factor: LPN’s disregard for 85% saturation and emergency cases distracting the team and leading to poor monitoring of the patient’s state.
Step 4. The increased amount of sedation happened because of the lack of monitoring, reporting, and other emergency cases, which led to the patient’s brain death.
Step 5. The mistakes can be avoided by monitoring the states of patients under sedation.
Step 6. The lack of attention, task delegation, and other emergency cases distracted the team and preconditioned poor monitoring during the sedation, which preconditioned the brain death. It is recommended to control such patients by measuring their vitals.

In such a way, the case shows that the main causative factor was how much sedation Mr. B received, while there were also many contributory factors. These include the state of the unit during the accident (new arrivals, emergency patients) and poor reporting (85% saturation was not indicated by the LPN). The combination of these aspects created the basis for the sentinel accident and outcome. Regarding the analysis, it can be recommended to improve collaboration within teams, reporting practices, and monitoring of patients under sedation.

Improvement Plan

The improvement plan should address the outlined causes of the problem and help to resolve them. First of all, it is critical to create a team responsible for discussing and outlining recommendations. It can consist of the ER charge nurse, nursing supervisor, representative of the risk management department, and a therapist. Discussing the case, they can determine the exact causes of Mr. B’s death and what could be done to avoid this undesired outcome. They should offer a causative statement, including the cause, effect of the cause, and how it influences the problem (Institute for Healthcare Improvement, n.d.). Using the collected information, the team can start working on recommendations to address the issue and avoid its repetition in the future. It might include the creation of a checklist that can be used during sedation procedures to increase patients’ safety, using all necessary equipment, observation of sedation policies, and effective task distribution (Shaw, 2019). Moreover, the work of teams during emergency cases can be regulated by improving leadership and delegating tasks regarding their priority. The given approach can help to improve the unit’s work and attain better outcomes.

The proposed improvement plan can be linked to Lewin’s change model. It implies the three major phases such as unfreeze, change, and refreeze (Hussain et al., 2018). The first one includes recognizing the necessity of change to attain positive shifts (Hussain et al., 2018). The creation of the team outlined above can be viewed as the unfreezing change as it would analyze the major factors linked to the problem, acknowledge its roots, and create plants and checklists to improve the situation. The second phase is the change itself, involving the implementation of outlined regulations and recommendations (Hussain et al., 2018). Proposals offered by the created team should be used by staff members to avoid undesired situations. Finally, the refreezing change, new alterations should become the part of the standard unit’s work, which is vital for improving results and avoiding the same issues in the future. In such a way, the proposed improvement plan correlates with Lewin’s change model and can be employed to address the discovered problem.

FMEA

FMEA is another useful tool that can be used to analyze the problem and improve outcomes. It consists of specific phases vital for collecting necessary information. First, it is vital to select a process for evaluation via the tool (Institute for Healthcare Improvement, 2022). Second, a team should be created to work on it. Third, the team should plan all steps that should be evaluated. The next step implies filling the table and recognizing failure modes. Furthermore, RPN to each failure mode should be assigned to determine priority (Institute for Healthcare Improvement, 2022). Finally, it is vital to assess analysis results and plan future improvement using available tools.

In such a way, the FMEA tool can be used for the case to determine the severity, occurrence, and detection of the process improvement plan:

Steps in the process	Failure Mode	Likelihood of Occurrence (1-10)	Likelihood of Detection (1-10)	Severity (1-10)	Risk Profile Number (RPN)
1. The RN should be present during the whole procedure	The nurse is absent because of other emergent cases	8	5	8	320
2. Patients should be monitored by using all necessary equipment	The equipment is not used or cannot be found	6	3	6	108
3. Sedation policy and procedure should be followed by all specialists	The staff is not familiar with the sedation policy and procedure	9	2	9	162
4. The RN should distribute tasks during emergency cases effectively	The RN fails to ensure all patients are provided with the necessary care	8	5	7	280
					Total: 870

Applying the given FMEA tool to the case, it is possible to acquire an enhanced vision of the problem, the causes that preconditioned its emergence, and the risks associated with it. At the same time, it outlines the effectiveness and importance of proposed improvements and measures that might be introduced to ensure the same actions will not occur again because of the increased attention to specific factors and conditions.

Interventions Testing

Testing the improvement program is another critical component of any positive change. It is vital to ensure that proposed alterations have the desired effect on the unit’s work and contribute to resolving the determined problem. For this reason, it is vital to outline a set of measures that might be used to test all improvements and guarantee they are applicable to the case. First of all, a random chart evaluation can be used to collect the necessary information. It would show the degree to which a new method is used and whether it is viewed as a helpful tool to improve sedation outcomes (Shaw, 2019). Moreover, using the given checklist several times, specialists would acquire the chance to improve it by adding necessary points that were previously not mentioned. It will help to enhance the effectiveness of the proposed intervention and guarantee it is accepted by staff members who are ready to use it in different scenarios.

Furthermore, the improvement program can be tested by analyzing the patients’ satisfaction levels, results, and the number of accidents. The major purpose of the proposed intervention is the reduction of sentinel outcomes. Under these conditions, the recent reports can be evaluated to understand whether the offered measures work and help to avoid mistakes, such as in Mr. B’s case. Additionally, the overall patients’ satisfaction will show whether they enjoy the improved quality of care and benefit from the interventions proposed to respond to the negative result. Finally, nurses and care providers can be asked about their vision of the proposed intervention and whether it helps them in everyday tasks (Shaw, 2019). It would help to acquire a complete vision of how the planned activities are accepted by teams and whether they are considered a part of the working process. In such a way, the given evaluation process is critical for controlling the improvement process and the work of the unit.

Leadership

The effective work of any health care unit depends on nurses and their leadership qualities. For this reason, they need to demonstrate their commitment and engagement in the most important areas. For instance, a nurse should offer incentives linked to her/his own experience and aimed at promoting the quality of care (Marquis & Huston, 2020). Appealing to past mistakes and how they can be eliminated would demonstrate leadership skills and encourage others to follow the example and support the proposed alteration.

Furthermore, a nurse with strong leadership qualities can focus on improving patient outcomes. It can be attained by paying more attention to patients’ needs and concerns, as the level of individuals’ satisfaction impacts results and effectiveness of treatment (Marquis & Huston, 2020). For this reason, leaders can encourage teams to build better relations with clients and ensure their basic needs are fulfilled. It would contribute to establishing trust relations between a care provider and a patient and ensure they share data necessary for the treatment process.

A professional nurse should also participate in the quality improvement processes. His/her leading positions can be outlined by being highly engaged in proposed interventions, motivated to promote positive alterations, and inspiring others (Marquis & Huston, 2020). A nurse can also collect qualitative and quantitative data from patients to ensure managers or other specialists possess relevant information about the issues that should be addressed to select the most powerful and working method. In such a way, nurses are central contributors to quality improvement in healthcare units.

Finally, involvement in RCA and FMEA analyses can also demonstrate a nurse’s leadership and commitment to quality improvement incentives. First, it means that a specialist is interested in improving the work of teams, which is a sign of a strong leader. Second, it requires recognizing existing flaws and mistakes and their detailed analysis, which is also a feature of an engaged and motivated person. In such a way, nurses have various opportunities for demonstrating their leadership qualities and improving the quality of care.

Conclusion

Altogether, the analyzed case shows the critical importance of analyzing undesired outcomes in a healthcare setting. Using RCA and FMEA tools, specialists acquire the chance to outline the factors that preconditioned the emergence of the mistake and undesired outcome. At the same time, it is vital to monitor the improvement process as it might help to make the offered interventions stronger. Finally, nurses should be leaders acting as the agents for change and facilitating the development of the unit. It would help to attain better results and higher patient satisfaction levels.

References

Hussain, S., Lei, S., Akram, T., Haider, M., Hussain, S., & Ali, M. (2018). Kurt Lewin’s change model: A critical review of the role of leadership and employee involvement in organizational change.Journal of Innovation and Knowledge, 3(3), 123-127. Web.

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

Institute for Healthcare Improvement. (2022). Failure modes and effects analysis (FMEA) tool. Web.

Marquis, B., & Huston, C. (2020). Leadership roles and management functions in nursing: Theory and application (10^th ed.). LWW.

Shaw, P. (2019). Quality and performance improvement in healthcare (7^th ed.). AHIMA.

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