Organizational Systems & Quality Leadership

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Table of Contents

Introduction
Discussion
Role of Nurses
References

Introduction

Nurses in healthcare organizations are mandated to perform a root cause analysis (RCA) by the joint board commission.RCA is a program usually conducted to solve the initial cause of events or problems which occur in the health practice (Cherry & Jacob, 2008). After the root cause analysis is conducted it is important to conduct a failure mode and effects analysis, this will help nurses indentify and establish the next cause of action. Failure mode analysis is conducted so as to ensure that the process goes through without being hampered.

Discussion

Factors that led to the Sentimental Event

The patient was diagnosed to have a good history of prostrate cancer and glucose tolerance. Earlier, the patient had visited the health center and the data revealed that he had high cholesterol and lipids in the body. These factors could have led to the pains and swelling of the patient. After the physician evaluated the patients file, he proceeded to give the patient some sedatives which were not effective. Furthermore the physician was attending to other patients and did not give much attention to this particular patient thus leading to his death. The nurses were also negligent on their duty of attending to the patient.

Change Theory

According to the book “The Planning of Change”, adults are obligated to change their attitudes, perspectives and actions. This is also applicable to nurses and they should change their attitudes towards the patients. Such changes in nurses and physicians will enable a smooth and successful treatment of the patients, thus avoiding fatal events (Ogden, 2007). Nurses should not only change their attitudes, but also the actions they conduct towards patients, some of the actions done by physicians or nurses do not concur with the healthcare code of conduct hence result to compromising the life’s of patients.

Failure Mode Analysis

With such improvements suggested above, the sentimental events which occurred to the patient would have been averted. This analysis has exposed that, the errors of the physician led to the patient’s death. The health centers should increase the number of nurses so that they are not overwhelmed by the number of patients who seek treatment in these places. It is also important to hire qualified nurses who are able to handle the patients (Ogden, 2007). The nurses and physicians who do not comply with the health care code of conduct, should be taken to interdisciplinary teams which comprise of the following people: The health center doctor, senior nurse and physician.

The pre steps of performing a failure mode and analysis procedure are;

Identifying the error: This involves the distinctiveness of the problem which led to the death of the patient and errors of the physician.
A block diagram: This is a systematic drawing of the analysis which will be conducted.
Worksheet: A worksheet is a document which contains very important information about the analysis to be done.

When performing a failure mode and analysis procedure one should consider the following steps;

Severity:-This resolves the modes and their effects based on the requirement of their functions. One failure mode leads to the failure of the other; once the modes have been indentified they are given a severity number (Cherry & Jacob, 2008).
Occurrence:-In this step the factor or the cause of the failure is identified and the number of times it has occurred. This should be done in a well documented manner.
Detection:-This process helps in the testing the efficiency of the earlier procedures. This procedure involves the issuance of detection numbers which range from the highest to the lowest, in terms of failure detection. The highest number shows that the failure will escape without being detected (Cherry & Jacob, 2008).

Role of Nurses

To prevent fatal occurrences in the health centers, nurses should ensure that they handle patients with care and also provide them comfort. Nurses should also administer the appropriate medication as prescribed by the physician, by doing so they will be preventing unnecessary accidents.

References

Cherry, B., & Jacob, S. (2008).Contemporary nursing: Issues, trends, and management (4^th Ed.).St. Louis, Mo: Mosby Elsevier.ISBN:978-0323-05217-7.

Ogden, J. (2007). Health psychology: A textbook (4th Ed.). Berkshire, England: Open University Press.

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