Organizational Systems and Quality Leadership Essay Sample

A. Complete a root cause analysis ( RCA ) that takes into consideration causative factors that led to the lookout event ( this patient’s result ) .

“A cardinal dogma of Root Cause Analysis ( RCA ) is to place implicit in jobs that increase the likeliness of mistakes while avoiding the trap of concentrating on errors by individuals” ( AHRQ. 2012 ) . The bar of mistakes is the chief accent of a RCA. The procedure begins with garnering informations in respects to the event. so the informations demands to be analyzed. and the concluding measure is to happen solutions to the mistakes that were found so that a reoccurrence of the same mistake doesn’t occur once more. The squad should dwell of nurses. doctors. druggists. healers. infirmary decision makers. Once the squad is assembled they should work through the RCA procedure. This should get down with the patient and staff involved in the mistake being interviewed so informations can be obtained that is of import to the state of affairs. The squad so works together to happen the root ( s ) of the job. Once the root job ( s ) is found the squad comes up with solution ( s ) to assist the mistake to non happen once more.

There were multiple smaller events that led to the inauspicious event in the instance of Mr. B. When the instance is looked at there are several things that can be identified as portion of the job. Human and installation mistakes can be portion of the consequence of the inauspicious event that occurred.

In this instance Mr. B. a 67 twelvemonth old male patient presented. to the rural infirmary that has a 6 bed Emergency Department ( ED ) . with terrible hurting to his left hip secondary to a autumn.

While seeking attention he came across some obstructions that led to his decease. One of the chief obstructions that he ran into was the staffing in the ED. which consisted of merely one Registered Nurse ( RN ) . Nurse J. . one Licensed Practical Nurse ( LPN ) . one Physician ( MD ) . Dr. T. and a secretary. Upon Mr. B’s arrival the the ED there were presently two other patients being cared for that were in stable status. During Mr. B’s stay in the ED. a patient was being brought to the ED in respiratory hurt who would necessitate immediate attending by the RN & A ; MD. Besides during this clip the two patients from earlier were waiting for their discharge instructions and the waiting room had become busier with more patients look intoing in to be seen.

The nurse could hold called for back up staff. or had the secretary call for extra aid at this clip. But no extra staff was called or was aid asked for. A nurse supervisor could hold provided extra aid at this point. but once more no call for aid was made. In the instance of Mr. B. the deficiency of nursing staff and support squad members. lead to inauspicious patient results. Extra preparation may be needed for the staff on responsibility in respects to protocols and when to name for excess support. Besides doing certain staff has preparation that is up to day of the month could hold prevented some of the mistakes that lead to the inauspicious patient results.

A-1. Discuss mistakes or jeopardies in attention in the scenario.

Human mistake played a function along with the insufficient staffing for the patient sharp-sightedness in the ED contributed to the causes of this event. Per the scenario when Mr. B arrived to the ED. he was hyperventilating. his leg was swollen in his calf and appeared shortened. along with ecchymosis ( contusing ) and limited scope of gesture ( ROM ) . Mr. B. had his hurting rated at a 10 out of 10. Mr. B’s history includes prostatic malignant neoplastic disease. impaired glucose tolerance. elevated cholesterin and lipoids. and chronic back hurting. This was brought up to the MD at the clip of the patients admittance to the ED. and a program to calm him and to relocate his hip was made. Mr. B’s current medicines. but non doses were evaluated upon admittance. Of which he presently was taking oxycodone for his chronic back hurting. Use of hurting medicines can increase the hazard of respiratory depression when used with other medicines. such as benzodiazepines.

The initial medicine ordered by Dr. T was diazepam 5mg IVP. and so 5 proceedingss subsequently without the intended sedating consequence. Dilaudid 2mg was ordered to be given IVP. Dr. T was non satisfied with the sedation degree and ordered an extra dosage of each of the medicines merely 5 proceedingss subsequently. It was at this point that the MD noticed that sedation wasn’t ab initio achieved because of the patients weight an his habitue usage of oxycodone which was being used to handle his chronic hurting in his dorsum. Nurse J. ne’er questioned the orders for medicines or the frequence at which they were ordered. It besides does non look that Mr. B’s vital organs were of all time checked in between medicine doses. This all contributed to the incident that occurred.

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After all the medicines were given Mr. B’s vital organs were as follows: Blood Pressure ( BP ) of 110/62. a pulse oximetry reading ( Pox ) of 92 % . At this clip Mr. B should hold been placed on auxiliary O. his respiratory rate ( RR ) should hold been checked and vital organs should hold been monitored more closely. Besides the respiratory healer could hold been called to measure Mr. B’s respiratory provinces while Nurse J. and Dr. T finished the sedation and decrease procedure. Per the scenario the infirmaries policy requires that patients that receive moderate sedation have uninterrupted BP. ECG. & A ; Pox supervising done. Nurse J. who was trained in the sedation procedure and policy. nor the MD followed protocol. The precautional steps that were required by the infirmary could hold prevented the result of Mr. B.

After the sedation and decrease that went good. the ED received a call about another critical patient. Mr. B’s is placed on of all time 5 minute BP cheques. and the Pox remains on the platinum and Nurse J. leaves the room to get down the new critical patient and is trying to dispatch her initial two patients. Vital organs at 10 proceedingss after the terminal of sedation and decrease are a BP pf 110/62 and a syphilis of 92. he remained without RR and ECG monitoring. Just his boy remains at the bedside. Mr. B’s alarms travel off and is heard by the LPN. the dismay shows a low Pox of 85 % and the LPN resets the dismay and rechecks the patients BP. The LPN requires more preparation in blood force per unit area proctor & A ; Pox readings and when the RN or MD should be notified. along with preparation on appropriate intercessions if the readings are low or high. If the appropriate preparation and intercessions would hold been done. the fatal event that occurred to Mr. B may hold been prevented.

Nurse J. . the LPN. and the MD continued to see new patients and discharge patients place. Mr. B per the scenario is non reevaluated by the RN or MD after the sedation or process. as required by policy. The dismay sounds once more and Mr. B’s boy comes out of the room to advise Nurse J. Upon arrival she notes that Mr. B’s BP is critically low at 58/30 and his Pox reading is 79 % .

There is no pulsation noted and the patient is non take a breathing. a codification is called for recitation attempts. The patient when connected to the ECG is found to be in ventricular fibrillation ( v-fib ) . It takes 30 proceedingss to obtain a normal bosom beat. but Mr. B. is intubated and needs the ventilator to breath. Mr. B has no self-generated motion noted at this clip. Per the household petition Mr. B is transferred to another installation for advanced attention. At this installation. life support was discontinued. as he was determined to hold encephalon decease. and Mr. B died.

B. Use alteration theory to develop an betterment program to diminish the likeliness of a reoccurrence of the result of the scenario.

One has to understand the influences on alteration in order for betterment to be able to take topographic point. Kurt Lewin’s alteration direction theory plants in three stages. 1. unfreezing ; 2. alteration or passage ; and 3. freeze or refreezing. “The purpose of the theoretical account is to place factors that can hinder alteration from happening ; forces that oppose alteration frequently called keeping or ‘static forces’ and forces that promote or drive alteration. referred to as ‘driving forces’” ( Sutherland. 2013 ) .

The first phase is the unfreezing phase. This is where persons are helped to understand why the alteration is necessary because of the hindering factors to alter were identified. ( i. e. what is the current policy and what the current jobs are within the policy ) . “Before old behaviour can be discarded and new behaviour successfully adopted. the equilibrium needs to be destabilized ( unfrozen ) ” ( Barakat. E. . Khudair. H. . Sarayreh. B. . 2013 ) .

In Mr. B’s instance. what could hold influenced the alteration. such as the witting sedation policy. was that there might non hold been adequate preparation provided. the preparation may hold been out of day of the month. and that the staff was excessively busy for the sum of patients. the badness of unwellness. and the monitoring that was required ; and hence. did non follow infirmary policy. Once barriers are identified. alteration can be shown to be needed. and so action can be taken so betterments can be made to forestall farther incidents. Staff needs to be made cognizant of the demand for alteration and the barriers must be identified so that the alteration can be effectual. Actions that can be taken is reeducation or retraining and farther resources. given to the staff. All of this needs to be done so that the alteration is understood and can go the new policy throughout the infirmary. Once the nee policy is in topographic point & A ; informations is collected it can be compared to the old information and farther instruction can be done in respects to witting sedation and the positive results seen since the alteration was implemented.

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The 2nd phase or the passage phase is when the alteration really occurs. It is of import that all parts of the alteration be evaluated. During this phase persons are larning the new ways of thought and transitioning from the old ways. They are more wiling to accept alteration during this phase. Change doesn’t come easy to most people and it can be scaring or uncomfortable. Continued support throughout this provinces is of import so that the alteration can be successful.

In Mr. B’s instance. alteration may include retraining in respects to the demand for uninterrupted monitoring when a patient is having moderate sedation. looking at staffing ratios. or holding staff on call to come in when more critical patients are geting. holding more in hospital staff that could be called upon to help in critical state of affairss. holding experts on the alteration be available to reply inquiries and to assist staff passage to the alterations. Besides more preparation of the staff in respects to the hazards of depressants and their metamorphosis could be helpful in forestalling farther events. Support needs to be a two manner street. in which staff feel comfy speech production to each other in respects to a patient position or orders that they don’t think are appropriate or may make the patient injury.

The 3rd phase is besides known as the refreezing phase. This happens when the alterations are in topographic point or stabilized and have been to the full accepted. so that all staff work in the same manner. Thought this phase the infirmary should go on to supply support to the staff and rating should be an on-going procedure so that if issues arise they can be worked through instantly. If the stairss are followed. it will assist the infirmary be successful and it will hopefully forestall another fatal result as in the instance of Mr. B.

C. Use a failure manner and effects analysis ( FMEA ) to project the likeliness that the procedure betterment program you suggest would non neglect. ( Identify the members of the interdisciplinary squad who will be included in the RCA and FMEA. )

Failure manners and effects analysis ( FEMA ) is another tool that is used in betterment procedures for quality. “Health attention failure manners and effects analysis is a widely used technique for measuring hazard of patient hurt by prospectively placing and prioritising possible system failures” ( Ashley. L. . Armitage. G. . Hollingsworth. G. . Neary. M. . 2010 ) . This procedure of measuring allows for the designation of countries in the procedure that may neglect. so that it can dress alteration before an mistake occurs.

In Mr. B’s instance. FEMA won’t alteration what happened. but it can be an effectual tool in outlining the new moderate sedation policy. in hope that mistakes can be prevented by any issues identified through out the procedure. The procedure needs to get down with a squad that is interdisciplinary. intending it should hold nurses of different accomplishment degrees. Physicians. Pharmacists. Respiratory Therapists. etc ; who use the procedure. and some that don’t use the procedure such as senior staff members. research workers. leaders and they need to work together. ( Ashley. L. . Armitage. G. . Hollingsworth. G. . Neary. M. . 2010 )

Success will be determined by the committedness of those involved. It is besides dependent on the clinicians with expertness to give recommendations and to give go oning support as the new procedure is implemented.

C-1. Explain how you would prove any intercessions to better attention in a similar state of affairs by altering the procedure of attention.

Necessary intercessions in a similar state of affairs of Mr. B’s could be recertification every twelvemonth or two depending on how frequently the policy is used in a section. There should be ample clip to travel through scenarios that could go on in a moderate sedation state of affairs. Staffing should be reevaluated during busy times in the section. or staff should be placed on call. Open communicating patterns should be expected and encouraged in the section so to forestall medicine mistakes. over medicine. or being afraid to name and inquire for aid. The environment should further squad work.

A procedure should be in topographic point for dual look intoing orders and pulling up critical medicines to be given in state of affairss such as this. A dual mark off should hold to happen with the two parties verifying the order and the drawn up medicine. A procedure should besides be in topographic point to hold staff cheque suites one time a displacement to do certain the room is stocked. supplies aren’t losing. and equipment is in working order. Those who check off the room. or didn’t look into the room demand to be held accountable if something is losing or non in proper working order. If this is done one time a displacement that means each room should be checked 2-3 times a twenty-four hours and would hopefully forestall losing points.

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Ongoing ratings would necessitate to be done in respects to the new procedures so that if any new or farther issues are happening. they can be addressed in a timely mode and alterations can be made. This would wholly be done in hopes of making teamwork and communicating between all staff members. so that an addition in patient safety and better attention can be given.

C-2. Discuss pre-steps for fixing for the FMEA.

A system must foremost be analyzed so that a new system can be developed and implemented. The pre-steps of fixing for FEMA include forming the squad and holding those members list what they see as failures in the system or procedure they are measuring. Once they have identified the failures. they must prioritise them so they can be addressed suitably. During the pre-steps the information the infirmary has is evaluated and compared to other informations. In this scenario the informations about moderate sedation procedure. the medicines used. and the preparation will all be evaluated. Data should include positive and negative parts of the procedure and the results should besides be included. once more positive or negative.

C-3. Describe the three stairss of the FMEA: badness. happening. and sensing.

“Each failure manner has a possible consequence and each possible consequence has a comparative hazard associated with it. The comparative hazard of failure and its effects is determined by three factors: badness. happening. and detection” ( ICMA. 2014 ) . All the factors are rated on a one to ten graduated table. with one being the least important and 10 being the most important.

Severity is related to the effects that would ensue from a failure manner ( which are patient injury or ne’er events ) if it would happen. In this scenario the badness was related to Mr. B’s concluding result. which was his decease. His decease occurred due to a system failure. Happening evaluation is the measuring for the procedure failure to go on. Detection evaluation is acknowledging a failure manner or a cause for a failure manner before a patient is harmed. Mr. B could hold benefited from the sensing evaluation if they system was in topographic point prior to his visit. as it should hold been noted that deficiency of staff. deficiency of equipment use. and of deficiency of communicating were all an issue prior to his visit.

D. Discuss the cardinal function nurses would play in bettering the quality of attention in this state of affairs

Nurses have a really of import function in the providing safe patient attention. A RN needs to be able to pass on good and work as a squad participant. They need to be up to day of the month on their cognition base and be prepared for what could go on in the worse instance scenario. The patient must come foremost and they need to be willing to recommend for their patients in any state of affairs.

In respects to Mr. B’s attention. some simple things could hold been done and his visit could hold had a different result. Nurse J. should hold made certain communicating was effectual when giving Dr. T. study on the patient after admittance. Besides Nurse J should hold communicated the demand for another nurse and the respiratory healer when the call came in for the patient in respiratory hurt. as she knew she was busy with the moderate sedation of Mr. B. and was trained in the policy & A ; the monitoring it requires. This would hold been moving as an advocator for her patient. and the new patient that was coming in. besides she would hold been utilizing her resources that were available. and utilizing great communicating accomplishments. All of this would hold allowed her to remain with Mr. B to make her appraisals and monitoring that is required with moderate sedation policy. that she was trained in. This all could hold led to a different result for Mr. B.


Agency for Healthcare Research and Quality ( 2012 ) Patient Safety Primers: Root Cause Analysis. Retrieved from hypertext transfer protocol: //www. psnet. ahrq. gov/primer. aspx? primerID=10 Ashley. L. . Armitage. G. . Hollingsworth. G. . Neary. M. ( 2010 ) A practical usher to failure manner and effects analysis in wellness attention: doing the most of the squad and its meetings. National Center for Biotechnology Information. Retrieved from hypertext transfer protocol: //www. ncbi. nlm. National Institutes of Health. gov/pubmed/ 20860241

Barakat. E. . Khudair. H. . Sarayreh. B. ( 2013 ) . Comparative survey: the Kurt Lewin of alteration direction. International Journal of Computer and
Information Technology ( ISSN: 2279-0764 ) Volume 02 – Issue 04. July 2013. Retrieved from hypertext transfer protocol: //ijcit. com/archives/volume2/issue4/ Paper020413. pdf

International Crisis Management Association ( 2014 ) . Failure manners and effects analysis ( FMEA ) . Retrieved from hypertext transfer protocol: //www. icma-web. org. uk/06-7_fmea. hypertext markup language Sutherland. K. ( 2013 ) . Using lewin’s alteration direction theory to the execution of bar-coded medicine disposal. Canadian Journal of Nursing Informatics. Volume 8 No. 1. 2. Retrieved from hypertext transfer protocol: //cjni. net/journal/ ? p=2888