Mr. B Case Analysis (Essay Sample)

Mr. B Case Analysis Student’s First Name, Middle Initial(s), Last Name Institution Affiliation Course Number and Name Instructor’s Name and Title Assignment Due Date Mr. B Case Analysis General Purpose of Conducting a Root Cause Analysis Conducting a root cause analysis involves a systematic approach of categorically highlighting the root causes governing an adverse event and the associated contributing factors. A root cause analysis serves as a fundamental step in developing effective interventions that help in reducing the occurrence of adverse events. The root cause analysis concept has its basis on the fact that identifying all the underlying factors to a problem is a precondition for establishing effective solutions (Institute for Healthcare Improvement, n.d.). Therefore, root cause analyses are common in the healthcare sector because they empower healthcare organizations to identify effective interventions that help in combating adverse events. Specifically, the root cause analysis is a common process in the context of medication errors as healthcare organizations seek to identify the fundamental causes of the errors that compromise patient safety. Healthcare organizations have used the root cause analysis approach to identify multiple contributing factors that interact at various levels and trigger medical errors. For this reason, the root cause analysis serves as an extensive investigation that precedes the development of practical solutions. Root cause analyses do not focus on individuals but on causative factors that interact to trigger adverse events. Explanation of the Six Steps Used in Root Cause Analysis Step 1: Identification of What Transpired The initial step in root cause analysis requires the healthcare professionals to recall and describe the event that transpired accurately. In this context, healthcare professionals might utilize a flowchart that creates room for an extensive description (Merrett, 2012). However, succeeding in this step requires careful consideration of all the elements that govern the event that transpired. Therefore, healthcare professionals should build a complete picture of the adverse event without leaving out details. Step 2: Determination of What Should Have Transpired The second step embarks on imagining an ideal scenario and highlighting the relevant standard procedures and protocols that would have resulted in a different outcome. In this context, the healthcare professionals create an overview of the accepted evidence-based standard procedure appropriate for the specific process that led to an adverse event (Institute for Healthcare Improvement, n.d.). Again, using a flowchart or other illustrative tools can foster effectiveness in developing an overview of all the relevant hospital policies and protocols that would have defined the ideal situation. Step: Determining the Causes The third stage outlines the specific causes that caused a deviation from the ideal outcome to the adverse event. Healthcare professionals should consider the underlying reasons that triggered the adverse event. The use of “Why” as a questioning approach for five consecutive times serves as the beginning point in establishing both direct and indirect contributing factors that caused the adverse event (Charles et al., 2016). A Fishbone diagram makes it easier to explore all the underlying causes that may have triggered the sentinel event. The focus is identifying as many factors as possible with a clear understanding that multiple factors interact to cause a sentinel event. Step 4: Determining Causal Statement The team of healthcare professionals conducting the root cause analysis should establish a correlation between the identified causative factors and the adverse effects (Institute for Healthcare Improvement, n.d.). The causal statement represents the observed correlation and forms the basis for developing solutions to mitigate the adverse effects. Step 5: Establishing List of Recommendations In this stage, the team of healthcare professionals embarks on a rigorous brainstorming activity to outline the potential recommendations that can mitigate the occurrence of the sentinel event in the future. Step 6: Writing of a Summary and Hearing Findings The final step in this process is developing a summary that highlights the adverse event, the ideal situation, the causative factors, and potential recommendations (Merrett, 2012). After developing the summary, the healthcare professionals disseminate the information to different stakeholders as an important step in setting up a quality improvement process. Applying the Root Cause Analysis Process to Mr. B’s Scenario Step 1 Mr. B visited the emergency department with his main complaints being severe pain in the left leg and hip area. He underwent the initial assessment, after which the physician designated the responsibility of administering sedatives to a registered nurse. The registered was to administer these sedatives to get Mr. B ready for the reduction process. However, Mr. B’s weight and continued use of oxycodone compelled him to receive an additional sedative dosage. Mr. B underwent the reduction process, and nurse J ensured that he was on the automatic blood pressure machine to monitor his vitals. The machine was monitoring and giving alerts at five-minute intervals. Since the emergency department had a lot of incoming patients, the nurse left Mr. B to attend to other patients. consequently, the alarm sounding in Mr. B’s room went unattended, even though it was an indication of low oxygen saturation. The Licensed Practice Nurse (LPN), who heard the alarm, went further to reset it without updating nurse J regarding the patient’s progress. The nurse only came to Mr. B’s room after receiving a notification from Mr. B’s son that the monitor sounded an alarm. The nurse assessed Mr. B, only to recognize that his blood pressure had become too low, and his oxygen saturation was significantly lower at 79%. Based on the nurse’s assessment, Mr. B had lost palpable pulse and could not breathe (Merrett, 2012). The nurse immediately initiated STAT CODE and a subsequent CPR accompanied by other interventions to restore the patient’s pulse. These efforts restored his pulse, but he became dependent on the ventilator. The family decided to move him to a tertiary facility for advanced care. Step 2 Based on standard procedures, Mr. B needed constant monitoring after reducing the blood pressure monitor, pulse oximeter, and electrocardiogram to ensure that he met specific discharge criteria (Charles et al., 2016). The trained nurse, J, had the mandate to monitor the patient’s condition to ensure that he regained full consciousness following the sedation process. When the LPN became aware of the sounding alarm, it was her responsibility to notify the registered nurse immediately to create room for prompt intervention. The LPN also had an obligation to notify the nurse of the declining blood pressure and oxygen saturation to initiate the necessary interventions. Step 3 The unexpected influx of patients into the emergency department is a factor that compelled the registered nurse to pay attention to different patients. For example, the case of a patient with respiratory distress translated to immediate attention, obligating the nurse to leave Mr. B alone and focus on a prompt intervention to save the other patient. According to Merrett (2012), handling patients in emergency departments simultaneously created room for adverse events because the nurse could not monitor Mr. B as required under standard procedures. Step 4 The causal statement linking the event to the causative factors is: Mr. B suffered low oxygen saturation and associated brain death after his conscious sedation process in reducing his left hip. He did not receive proper monitoring of his vitals and prompt interventions. Step 5 The facility needs to hire more staff members in the emergency department to prevent the recurrence of overburdening registered nurses. The LPNs in the facility need training programs on effective communication with other healthcare providers to enhance delivering quality care. Registered nurses also require training on handling patients in the emergency department and critically monitoring their vitals (Charles et al., 2016). Establishing and reinforcing an interdisciplinary team approach will make it easier for all the healthcare professionals to collaborate in providing care to patients. Step 6 The facility will establish policy changes and call for a debriefing of all the stakeholders. During the debriefing, the stakeholders will receive a summary of the root cause analysis and participate in developing meaningful solutions. Proposal of a Process Improvement Plan to Decrease the Likelihood of a Recurrence of the Scenario Outcome The healthcare facility should adopt a multidisciplinary team approach that will help in promoting patient safety. The multidisciplinary team will comprise different healthcare professionals who can set goals in a bid to prevent medical errors (Van de Ven et al., 2010). Moreover, healthcare providers will need training programs to increase their capacity to make informed decisions and deliver quality care. The healthcare facility will focus on undertaking regular evaluations to establish the effectiveness of these interventions and develop the necessary modifications. How Each Phase of Lewin’s Change Theory on the Human Side of Change is Applicable to the Proposed Improvement Plan Lewin’s model involves three stages: unfreezing, the change process, and refreezing. During the unfreezing stage, the change agents create a favorable environment for the change process. Unfreezing requires a rigorous approach to preparing for the proposed change by demonstrating the urgency for change and handling resistance (Harrison et al., 2021). The healthcare facility will prepare for chang...