NSG WGU-C489 Task 2.

NSG NSG WGU-C489 Task 2. Organizational Systems and Quality Leadership SAT Task 2 Stephanie Osborne Western Governors University July 21, 2020 Section A The general purpose of conducting a root cause analysis (RCA) is to find system flaws that led to errors in care. RCAs do not focus on blaming individuals involved in the incident, they focus on contributory factors that existed and failed defense systems that enabled error to occur. In order to perform a RCA, you need a team of four to six different professionals from all levels of the organization with knowledge of the incident. This team may include patient representatives (not persons involved directly in the event), staff members either directly or indirectly involved in the process being evaluated, subject matter experts, and experts in the RCA process. (Institute for Healthcare Improvement [IHI], n.d.) When conducting a RCA, there are usually six steps to take during the process. The first step is to accurately identify what happened and in what order the events took place. It is often helpful for the team to create a flowchart or visual aid to see what happened at each step of the event. During the second step, the team must determine what should have happened under ideal circumstances. Again, a flowchart will be helpful to create each step during the event. Now the team can compare the two flowcharts and see areas where the system failed. In step three the team tries to determine the factors which contributed to the event. They must look at both direct and indirect factors. Experts say it is helpful to “ask why five times” in order to get at the root cause. Step four links the cause to the effect and back at the event that began the RCA process. They must develop a causal statement including three parts: the cause, the effect, and the event. The next step is making a list of recommended action changes that may prevent the error and event from happening again. A strong action change should significantly reduce the likelihood of the event from happening again. An intermediate action change should control the root cause whereas a weak action change is likely to be ineffective. Finally, the team will summarize what they found in writing and share it with key players. This step can lead to improving policy and procedures. (IHI, n.d.) There were many causative and contributing factors present on this day. Mr. B was brought in for a hip fracture and needed conscious sedation in order to reduce the hip. There was one RN, one LPN, one ED physician, one secretary, one in house RT, and standby staff available. All hospital equipment was available and functional. Conscious sedation was started on Mr. B without the in house RT at bedside. Mr. B was not placed on ECG monitoring or supplemental O2. Nurse J was trained in conscious sedation, ACLS, and in good standing with the hospital. After the hip reduction took place, Mr. B was left alone with his son on continuous BP and SpO2 monitoring but not monitoring ECG or RR. He had not met the criteria to be discharged from the conscious sedation protocol yet. The ED is now expecting an acute respiratory distress patient that is going to take Nurse J away from this patient. No additional staff was called in. The ED lobby has become full of new patients and there are two other patients that need to be discharged. The LPN responds to Mr. B’s “low O2 saturation” of 85% alarm and only resets the machine and cycles the BP. Mr. B’s son comes out of the room a few minutes later saying the “monitor is alarming”. Nurse J finds the patient not breathing and with no pulse. She calls a stat code and Mr. B is eventually intubated, stabilized, and flown to another hospital where he ultimately dies seven days later. What should have ideally happened on this day is that staff on standby be called in. They could have been called in before the conscious sedation began, knowing this procedure was going to take the RN a while to complete. RT should have been involved and at the bedside while it was taking place. The ECG should have been monitored the whole time and the patient placed on supplemental O2 throughout the procedure or at least when the LPN noticed “low O2 saturation” of 85%. Nurse J should not have left this patient’s bedside until he had completed conscious sedation meeting the criteria of fully awake and VSS. If staff wasn’t already called in, once the paramedics called about the patient in respiratory distress coming in, additional staff should have been called in to help. The secretary could call in staff as she saw the ED filling up with patients. When the LPN noticed the “low O2 saturation” alarm, a full set of VS should have been taken too. She should have called the RN, RT, and the ED physician to the bedside and performed a complete assessment including LOC, RR, BP reading, and ECG rhythm analysis. Intervention at any of the parts above could have prevented Mr. B from coding and ultimately dying. There are many direct and indirect causes that happened in this event. The fact that Mr. B was opioid dependent made him harder to sedate. It is not clear how much opioids Mr. B takes daily. Was his weight recorded correctly? Did the MD wait long enough for the medications to take effect before the next dose was ordered? Not enough staffing to handle the situation and additional staffing was not called in. The patient was not properly monitored on ECG nor was he given supplemental O2 when he needed it. The conscious sedation protocol was not followed in its entirety. RT was not called to help with the conscious sedation. The LPN did not alert the MD or RN when the patient was alarming for “low O2 saturation”. The RN was too busy with the other patient in respiratory distress to go check in on Mr. B. There was a lack of staff communication. The ED was understaffed and quickly became busy. Mr. B was not properly monitored during conscious sedation nor was the protocol properly followed. The RN was too busy to check in on Mr. B and the LPN did not properly respond to the “low O2 saturation” alarm. These factors ultimately contributed and lead to Mr. B’s death. Section B The recommended action change I would implement would first be for the secretary to call in additional staffing once there are a certain number of patients waiting, when a conscious sedation is to take place, when a new emergency is coming in, or when it seems fit to call additional staff. There needs to be a protocol in place for how and when to call in staffing as often the current staff are so busy they don’t realize they need help until it is too late. The secretary can alert the ED staff so they know that there are more patients to be seen and that more staff is coming. The ED staff must also follow protocol for calling in the additional staff when they see that they can be easily overwhelmed. For example: once there are five patients in the waiting area, staff need to be called in; once there is conscious sedation to take place, staff need to be called in; once there is an emergent respiratory distress coming in, staff need to be called in; if the number of admitted patients reaches five, staff need to be called in. Staff need further education about what abnormal vital signs need to be reported, who to report them to, and what to do immediately. For example: if O2 sat 92%, administer 2L O2 and call RN to bedside; if unable to rouse patient, call RN to bedside; if SBP 100, repeat BP and call RN to bedside. Make a conscious sedation check list containing recommended doses and how often to administer them, what to monitor during and after the procedure, who to have at the bedside, what equipment to use, and when the patient qualifies to discharge. The computer could have a forcing function that does not allow for overdose of medication or too much to give too fast. The MD and RN must use good communication skills like call back where you repeat what you heard to make sure you are doing the right thing and closed loop communication. Lewin’s Change Theory has three steps: unfreezing, change, and freezing. In the first stage, unfreezing, people must let go of their attachment to the old way of doing things. Staff will need to understand why the change is important and how it is going to be implemented. It is often hard for people to let go of the old way of doing things as it is so familiar and comfortable to them. People in general do not feel comfortable with change. In the second stage, the change takes effect. Staff may need support during this difficult time to adapt to the changes. Then finally, freezing occurs when the staff have officially adopted the new change and are actively participating in it. The freeze or “re-freezing” included new protocols and procedure and rechecks to make sure staff are adhering to the new way. (IHI, 2020) For this scenario, during the unfreeze, the staff will need to be educated about the importance of having additional staff come in to help. They need to let go of the “I can do it” mentality. Often pride can get in the way of staff calling in for help. They think it makes them weak. Staff will need to be guided to know that it is not a sign of weakness nor will it reflect badly on them if they call in for help. They will be presented with data about how the quality of care goes up when additional staffing is used properly and sentinel events can be avoided. In the change process, they will utilize the proposed protocol or flow chart that helps them determine if additional staffing is indicated. They will also know and be able to call in staffing when it feels like they need it. They will not experience repercussions for calling the additional staffing in. Staff will feel safe and supported during the whole process. Then freeze is where the final protocol for proper staffing is set and consistently used. Management will check in and make sure the extra staff is coming in on time and being called appropriately. Section C Failure modes and effects analysis (FEMA) is a tool used to find system errors before they happen. A team of experts in all areas of the process under investigation are used. This tool helps predict how and where a system may fail. It also tries to predict the extent of the failure or how severe the harm would be if the system failed. In doing this proactively, it can prevent harmful events from happening in the first place. Every step of the process under investigation is examined, looking for ways to prevent errors that could happen by revising the protocols. (IHI, 2017) There are five steps in the FMEA process. The first step is to decide which process to evaluate. If it is a large process, it may need to be divided up into smaller sub-processes. Next, a team of experts needs to be made. The team will need to have at least one expert involved at each point of the process. Everybody may not need to be involved for every step but at least the one that directly involves their part of the process. The third step is to agree and list every step in the process. A flowchart may be a helpful visual aid for this step. In step four, a FMEA table is completed. The table lists all the steps in the process that you came up with in step three. These are listed in the far left column. The next column is the failure mode where you list all the things that could go wrong. The next column is failure causes where you list why the failure might happen. Then in the next column you list failure effects which would be the consequences if the failure happened. Then on a scale of 1-10, you list the likelihood the failure would occur with 10 being most likely. In the next column, you list the likelihood the failure would be detected where 10 is the most likely to not be detected. Then you rank the severity of harm the failure might have where 10 is the most likely to cause severe harm if the failure happened. Once you have all your numbers, you multiply them together to get a risk profile number (RPN). The higher the RPN, the more severe the impact the failure would make and that is the part of the process to focus on first. The team must now list possible ways to improve the process and make it safer by trying to avoid the potential failures identified. In step five the team focuses on the top ten highest RPNs to improve. This is where protocols are changed, forcing functions are added, verification steps are added, alert screens, or double-checks may be added for safety. It is often helpful to train staff to recognize early warning signs and implement early interventions. Regular training drills may be utilized to keep staff knowledgeable about what to do and what to look out for. (IHI, 2017) FMEA Table List 4 steps in your Inprovement Plan Process List 1 Failure Mode per step Likelihood of Ocurrence (1-10) Likelihood of Detection (1- 10) Severity (1- 10) Risk Priority Number RPN 1. Secretary notice increased # patients in waiting room – call additional staff Secretary notices increased # of patients but forgets to call in additional staff 4 6 5 120 RN calls for additional staff prior to conscious sedation RN is too busy and forgets to call additional staff 8 2 6 96 Staff calls for help when emergency is due to arrive Staff being called in does not get the message 2 1 7 14 Appropriately call for additional staff when needed Staff does not show up for hours 3 1 8 24 Total RPN (sum of all RPN’s)_254_ Section D The way this intervention could be tested prior to full implementation is to do a trial run. The staff working in the ED will need to be educated about the new protocol being trialed, how to call for backup staff, when to call, and that this is not in any way going to look badly on them how often they use it. Over a month period of time, the number of patients coming to the ED will need to be monitored to see possible trends in times where there may be a greater need for extra staff. Perhaps staffing could be increased during these times automatically instead of relying on a call in. The number of conscious sedatives will need to be monitored along with how often staff called in the standby staff for these procedures. You will want keep track of how long it takes staff to arrive for work after being called in and if the procedure waited for the additional staff to arrive prior to beginning. Another thing to monitor is if the backup staff are answering the phone calls and responding to the call in. How many times were they unsuccessful in calling in the standby staff? How long does it take for standby staff to arrive? The protocol may need to state that standby staff must arrive for work within 45 minutes of the original call. Staffing options may need to be changed if unreliable staff are detected. Throughout the trial, the acuity of patients must be monitored as well. How many sentinel events happened? How many codes? How many severely sick emergency patients were brought in by paramedics? Was extra staffing called for in a timely manner? All these things will need to be monitored for during the trial. Section E Nurses have a unique role in healthcare. They are at the frontline every day. They spend the most time with patients, their families, and peers. The nurse as a leader is one who is approachable, friendly, and helpful. She is knowledgeable in most areas and willing to teach and guide her peers. She is able to recognize areas in need for improvement and speak up to make a change where needed. She promotes quality care by demonstrating excellence in clinical skills, communication, and knowledge. She has to make sure the multidisciplinary team is aware of patient preferences for treatment. She is the advocate for the patient to ensure they get the care they need and deserve. Making the patient part of the care team helps to improve their outcome. When patients are involved in their care, they are more likely to follow recommendations. If patients are told what to do and they do not agree, they will not be likely to follow the recommendation and thus not have good outcomes. The nurse as a leader can help influence quality improvement activities by making suggestions for improvement. As the frontline worker, she sees what goes on and is involved in near miss activities where harm could have come to the patient. She is often the final defense for the patient. Again she must communicate with the team when she senses error or potential danger. By speaking up, she can make a difference in patient care, outcomes, and process changes. According to Cherry (2017), in order to be an effective leader, you need three different types of skills: conceptual, human and technical. They are willing to teach and share their knowledge with others and also work on their own weaknesses by learning in areas they aren’t strong in. They are committed to excellence and are supportive of the hospital’s mission, values, and goals. They understand the complex needs of the healthcare system and the need to improve patient safety while reducing cost. They encourage staff to improve their skills and knowledge. The nurse as a leader does not have to know all the answers but she knows how to get the answers. They are willing to participate in quality improvement activities by bringing their vast knowledge to the table and help improve areas that are weak in the system. References Cherry, B. (2017). Nursing leadership and management. In B. Cherry & S. R. Jacob (Eds). Contemporary nursing: Issues, trends, and management (7th ed., p. 298). St. Louis: Mosby Elsevier. ISBN: 6 Institute for Healthcare Improvement (n.d.). Patient safety 104: Root cause and systems analysis summary sheet [PDF File]. Retrieved July 20, 2020 from: https://srm-- Institute for Healthcare Improvement (2017). QI Essential toolkit: Failure modes and effects analysis (FEMA) [PDF File]. Retrieved July 20, 2020 from: https://srm-- Institute for Healthcare Improvement (2020). QI 201:Planning for spread: From local improvements to system-wide change. Lesson 1: How change spreads. Retrieved July 20, 2020 from: d90849f183d4/ea07c796-abd8-b6c793/lessonDetail/2adf747a-862f- 4862-ab0c-f05b67/page/1 d90849f183d4/ea07c796-abd8-b6c793/lessonDetail/2adf747a-862f- 4862-ab0c-f05b67/page/1