Root Cause Analysis (RCA) to a Healthcare Scenario Sentinel Event (Other (Not Listed) Sample)

WGU C489 task#2 Root Cause Analysis (RCA) to a Healthcare Scenario Sentinel Event Student Name Institutional Affiliations Instructor Date * The General purpose of conducting a root cause analysis (RCA). Root cause analysis (RCA) is a method used to identify the underlying cause of an incident or problem. RCA is a systematic approach that uses data collection, problem analysis, and corrective action planning to identify the source of an incident or problem and develop a plan of action to prevent similar incidents from occurring in the future. The main purpose of conducting a root cause analysis (RCA) is to determine the source of an incident or problem and develop a plan of action to avoid similar situations in the future. RCA is a comprehensive approach that helps to identify the source of an incident or issue and develop corrective steps to prevent similar incidents from occurring again ("regulatory imperative to perform root cause analysis," 2016). The intent of RCA is to identify the actual cause of an incident and create solutions to prevent similar incidents in the future. RCA can also identify underlying processes and procedures that may be contributing to the incident or problem. 1 Six steps used to conduct an RCA, as defined by IHI * Define the problem: The first step in RCA is to clearly define the problem that needs to be addressed. This includes identifying the problem, defining the scope of the RCA, and establishing the team that will be responsible for conducting the RCA (Perry et al., 2013). * Collect data: The second step is to collect data from various sources, such as incident reports, patient records, interviews with staff, and observations of the incident. This data will be used to analyze the problem and identify potential causes * Analyze the data: This step involves analyzing the data collected to identify potential causes of the problem. This includes looking for patterns or trends in the data that could indicate the cause of the problem. * Identify potential root causes: After analyzing the data, the team can identify potential root causes of the problem. This step involves looking for commonalities among the data collected to identify the likely cause of the problem. * Validate root causes: The fifth step is to validate the root causes identified by the team. This involves further reviewing the data and conducting additional research to verify the root causes. * Develop corrective action plan: The final step is to develop a corrective action plan to address the root causes identified. This plan should include specific actions that can be taken to prevent similar incidents from occurring in the future (Perry et al., 2013). Applying the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome. The root cause analysis (RCA) of the sentinel event in the scenario reveals a number of causative and contributing factors that led to the outcome. The first causative factor was the inadequate staff-to-patient ratio, which limited the ability of the staff to adequately monitor the patient and respond quickly in the event of an emergency. The ED staff was caring for three patients at the time Mr. B arrived, and with only two nurses, one secretary, and one emergency department physician, it was difficult to provide adequate monitoring and care for each patient. This inadequate staffing ratio likely contributed to the delayed response in addressing the patient’s deteriorating condition (Okes, 2019). Another contributing factor was the lack of monitoring equipment, such as ECG and a pulse oximeter, which could have alerted the staff to the patient’s deteriorating condition. In addition, the nurse who initially responded to the patient’s O2 saturation alarm was not adequately trained to recognize the significance of the alarm and take appropriate action. The patient had a history of impaired glucose tolerance and prostate cancer, which may have contributed to his inability to respond to the administered medications. Furthermore, Nurse J had not completed the hospital’s moderate sedation training module, which may have contributed to her decision to administer higher doses of medication than were necessary. The nurse was unfamiliar with the acceptable dose ranges for moderate sedation, which may have led to her administering higher doses of medication than were necessary to achieve the desired level of sedation ((ABS Consulting et al., 2014). Another contributing factor was the lack of monitoring equipment, such as ECG and a pulse oximeter, which could have alerted the staff to the patient’s deteriorating condition. The lack of these monitoring devices likely hindered the staff’s ability to quickly recognize the patient’s declining condition, leading to a delayed response. Notwithstanding, the nurse who initially responded to the patient’s O2 saturation alarm was not adequately trained to recognize the significance of the alarm and take appropriate action. The nurse reset the alarm without taking any further action, likely due to her lack of training in recognizing and responding to the alarm. Again, the patient had a history of impaired glucose tolerance and prostate cancer, which may have contributed to his inability to respond to the administered medications. The patient’s medical history could have affected his ability to respond to the medications, resulting in a delayed response and ultimately leading to the sentinel event. * Proposed process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome The process improvement plan should focus on improving patient safety and preventing a similar incident from occurring in the future. To start, the hospital should establish a more thorough moderate sedation policy. The policy should include the requirement that all practitioners who perform moderate sedation successfully complete the hospital’s moderate sedation training module. The training module should include in-depth information on drug selection, dose ranges, and other important items related to moderate sedation. Further, the hospital should consider instituting a two-person rule for monitoring sedated patients (Okes, 2019). This means that two people should be present in the room at all times to monitor the patient’s vital signs and overall condition. If the patient’s condition changes or the vital signs become abnormal, one person can immediately notify the other to take appropriate action. The hospital should also consider implementing a system of regularly scheduled audits to ensure that all staff members are following the established policies and procedures related to moderate sedation. During the audits, the staff should be evaluated to ensure that they are competent in the knowledge and practice of moderate sedation. Also, the hospital should invest in additional equipment, such as cardiac monitors, that can be used to monitor patients’ vital signs and condition more accurately. This equipment can be used in addition to the regular vital sign monitoring and can alert staff to any changes in the patient’s condition. How each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan Lewin’s Change Theory can be applied to the proposed improvement plan in the following ways. The Unfreeze phase involves creating the motivation and the need for change by identifying the problem and assessing the current situation. In the case of the proposed improvement plan, the problem is that the patient suffered a serious adverse event in the emergency department. Through an assessment of the current situation, the hospital can identify the need for change and begin to develop a plan to improve patient safety. The Change phase involves implementing the plan and making any necessary changes. In the case of the proposed improvement plan, this involves implementing the more thorough moderate sedation policy, instituting the two-person rule for monitoring sedated patients, regularly auditing staff to ensure they are following the established policies and procedures, and investing in additional equipment (Crosby, 2020). The Refreeze phase involves maintaining the changes and making sure they are sustainable over time. In the case of the proposed improvement plan, this involves regularly auditing staff to ensure they are following the established policies and procedures, making sure the two-person rule is being followed, and making sure the additional equipment is being used correctly and maintained properly. * The general purpose of the failure mode and effects analysis (FMEA) process The general purpose of the Failure Mode and Effects Analysis (FMEA) process is to identify potential failures, to evaluate the associated risks, and to develop solutions to eliminate or minimize potential failures. The FMEA process is used to identify potential failure modes, their causes and effects, the severity of the effect, and any preventative actions that can be taken to reduce the risks associated with the failure. The FMEA process is an important tool for improving product quality and reliability, and is used in many industries, including the medical field (Stamatis, 2019). 1 Describe the steps of the FMEA process as defined by IHI The steps of the Failure Mode and Effects Analysis (FMEA) process as defined by the Institute for Healthcare Improvement (IHI) are as follows: * Process identification: The first step is to identify the process or system that is to be evaluated. This includes defining the process, the components, the people involved, and the environment. * Identification of potential failure modes: The next step is to identify the potential failure modes for each component or step in the process. These failure modes should include any potential failure that could lead to an undesired outc...