Organizational Systems Essay

Root casing analysis (RCA) is a tool designed to wait on identify non plainly what and how an event diered, but as well why it happened. We bed bewitch from this scenario that the pedigree fountain is the lack of oxygen given to this diligent, however it is non the exclusively cause. A string of events lead to this patients demise. The first and most historic cause was that hospital policy was overlooked. In the scenario it stated. Root Cause Analysis (RCA) is a tool designed to help identify non only what and how an event occurred, but also why it happened. We gage see from this scenario that the root cause is the lack of oxygen given to this patient, however it is non the only cause. A string of events lead to this patients demise. The first and most important cause was that hospital policy was overlooked. In the scenario it stated A mode ordain sedation/analgesia (conscious sedation) policy requires that the patient remains on invariable B/P, ECG, and pulse o ximeter throughout the procedure and until the patient meets specific resign criteria (i.e., fully awake, VSS, no N/V, and able to void).The trained nurse had the equipment to retard that this policy was sustained, however failed to perform her duties as required by this policy. The back up event is that the LPN reset the alarm and made no lather to provide an intervention for the alarm. The LPN did not inform the RN of the O2 vividness level. The LPN Was not trained properly. The third event was that there was not enough faculty c exclusivelyed in for the level of acuity that these patients had. The administration should permit been made aware of the emergency coming in and c every(prenominal)ed in much ply to accommodate the staveing need. The errors or hazards in care in the scenario were that the RN failed to follow hospital policy to continuous monitor the patient. LPN was not properly trained to handle patients with a higher acuity. LPN failed to account and respon d to the alarm. It would be adjuvant if the parties composite with this event come together and discuss on what failed and how they can improve the system.To decrease the likelihood of this calamity again the data collected from the RCA needs tobe presented and a end needs to be implemented so that all the staff can know what to do if this situation occurs in the future. Implementing a plan where all the parties are involved pull up stakes insure that policy that is implemented impart be followed through and a since of groupwork and collaboration will be felt. Lewins shift lay talks close people that are stock-still in their idea of how certain soures should work, and need to be unfrozen in their run in rear to venture a change. In the scenario, the staff may be stuck in a surgical process of how they perform their job. When things in the ER got busy, The nurse may have felt that since she has experience and is commensu reckon she could handle things in the ER wit h just the help of the LPN. If this Nurse was not frozen in her old ways she would have realized that cunning when to call for help early enough is a nursing gravest cardinal behavior.Sometimes being stuck in your old ways is not what is scoop for the patient or yourself. If the future with change this Nurse has the electromotive force to be a good counsel for other nurses and staff. She will be helpful in supporting change for the better of the patient. Lewins hour model talks about what needs to be changed in a situation. In the scenario, the process of how moderate sedation is performed and followed up for each and every patient in any department needs to be changed. In order to make a change, staff needs to become involved and transform why this change will benefit the patient and the nursing staff. In order to make a change and have it successful the staff will need intrinsic motivators. According to Lewins change theory the staff will need to first, be open to the idea of this change and second, see how it can benefit the select of care given to patients. modify the moderate sedation policy to include a one on one qualified staff member to stay with the patient after(prenominal) sedation at all times until discharge criteria is met. Staff education, annual education and possibly mock sedation scenerios could help the staff learn in a real life situation what could go wrong and what could be done better. When the change has been introduced. Trial and errors are worked and hone and staff starts to use these changes in practice. It has a possibility to become linguistic rule to them and whence the refreezing process can begin. Lewins refreezing process is referred to as, once rising change is in practice the staff will and then start to implement that changed process in common procedure, cause a refreezing process of new and improved procedure. After, Nurse J and the other staff members inthe ER and everywhere else in the hospital, practic e and start applying these new changes into their everyday routine after several weeks, it will become second genius to them (Change theory, February) disaster modes and cause analysis (FMEA) identifies all possible ruins in a service rendered. Failure modes means the ways, or modes, in which something mightiness fail. Failures are any errors or defects, especially ones that affect the customer, and can be potential or actual. effectuate analysis refers to studying the consequence of those failures. (The flavor Toolbox.2004) The interdisciplinary team that should be included in the RCA and FMEA are everyone involved like all doctors, RNs, LPN, administrators, and the joint commission. We would start by ontogeny gaits to assess risks of failure to patients in the process that is being used. The pre- mistreats necessitate to implement FMEA is that the interdisciplinary team needs to be in commensurateness with how many steps and the steps that accurately describe the process . For each Failure mode the team needs to assign a risk antecedence military issue (RPN), this is used to detect the likelihood of happening, detection and severity.For every failure mode identified, the team should answer the following questions and assign the appropriate score. (the team should do this as a group and have consensus on all values depute) 1) How potential is it that this failure mode will occur? 2)Assign a score between 1 and 10, with 1 meaning very unconvincing to occur and 10 meaning very likely to occur. And 3) How likely will the error be caught before causing harm to the patient. (IHI.pdf) The first step in FMEA is to analysis how likely is it that this failure mode will occur and its severity of affect on the patient. To do this the hospital would assign a severity number to the process step that they are testing. The FMEA would have number 1 through 10. 1 would mean no harm would be done to the patient, 5 would be moderate harm to the patient and 9 or 10 would mean that the severity would be very spoiled with the worst possible outcome for the patient.Like in the case scenario if the process step they chose was with no equipment for monitoring of a patient after sedation and without staff present or staff present and all equipment was present. The process failure mode was that the patient stops breathing and no one or no equipment was present. The number value for this scenario would then be assigned the highest number because of the high likelihood that it would have the worst outcome for the patient. The second step in the FMEA isto analyze how often the error or potential trouble is likely to happen in the process. The occurrence subdue also has a numeric value of 1 to 10. 1 would be that the worry could occur in under 0.01 to every 1,000 people, 5 would represent about 5 people to every 1,000 people and 10 would have the highest occurrence of over 100 people to every 1,000 people, which would make it very likely that the ev ent will occur.The hospital staff would than take their process step of not monitoring a patient after sedation and rate the occurrence of the process at how likely the event would happen. The hospital then can look at data from other hospitals that did not monitor patients after sedation to see the likelihood that they stop breathing to rate the number. The third and last step is how likely the error or problem can be caught before reaching the patient and on what point of harm it can cause to the patient. The same principle applies to the detection scale of a scale of 1 to 10. All of the numerical scores would then be multiplied together Severity x Occurrence x Detection = Score.A score over 100 would prompt the hospital to look into the problem to a greater extent closely and anything below that number they may want to take off their agenda and focus on the more dangerous outcomes for the patients. (Forrest, 2010) The key role nurses would play in improving the quality of care i n this situation. Are to implement a plan of action. They can sponsor classes for other staff to get educated. They can attend drills to commit different scenarios to be prepared for other events. Having nursing staff advocate for the change will also help the other staff follow by example when changes are made, especially if they know the reason is to help prevent harm to patients in their care. Nurses with the right tools, guidelines and policies are able to make sure that the care is the best quality for their patients.ReferencesChange theory. (January, 2014, 02). Retrieved February 20, 2015, from http//wgu.hosted.panopto.com/Panopto/Pages/Viewer.aspx?id=e348f20b-e819-43e4-abcaf191f99bcFailure Modes and Effects Analysis (FMEA) Tool. (n.d.). Retrieved February 20, 2015, from http//www.ihi.org/resources/FailureModesandEffectsAnalysisFMEATool_IHI.pdfForrest, G. (2010, December 31). Quick guide to failure mode and effects analysis. Retrieved February 20, 2015, from http//www.isixsig ma.com/tools-templates/fmea/quick-guide-failure-mode-and-effects-analysis/IHI Institution for Healthcare Improvement. (n.d.). Lesson 5 testing changes (Pages 1-2). Retrieved from http//www.ihi.org/education/ihiopenschool/Pages/default.aspx Policy break Root cause analysis. (n.d.). Retrieved fromwww.precisionlens.net/UserFiles/rootcause-analysis.docNancy R. Teague The Quality toolbox, 2nd edition, ASQ Quality Press, 2004, pages 236-240.