Root Cause Analysis and Failure Mode and Effect analysis (Research Paper Sample)

Root Cause Analysis and Failure Mode and Effect analysis Student’s Name Institutional Affiliation Course Name Professor’s Name Due Date Root Cause Analysis and Failure Mode and Effect analysis Introduction Root course analysis (RCA) is a systematic process of finding and analyzing the possible sources of a problem to identify the exact course and solve it effectively. Failure mode and effect analysis (FMEA) is a systematic, proactive method used to evaluate a process, predict possible failures, assess possible effects of the identified possible failures, and isolate areas that require change and work on them efficiently (Institute for Healthcare Improvement, 2018). RCA and FMEA work together to analyze events, identify flaws, and lay strategies to prevent the occurrence of similar events in the future. RCA identifies the real cause of the problem, particularly system causes, rather than blaming individuals for the flaws. FMEA focuses on identifying interventions and possible failures in these interventions and mitigates them, preventing the occurrence of such events in the future. To this end, this paper offers a root cause analysis of patient complications following hip pain intervention at a healthcare facility. Steps in Conducting an RCA The Institute for Healthcare Improvement (2018) explains that the Root Cause Analysis process follows six broad steps. The first step is identifying and explaining what happened. In this step, the RCA team uses charts and diagrams to explain the event details. This is an integral step, and when details are left out in this step, the whole RCA process may be flawed. The second step is defining an ideal situation or explaining what should have happened. The ideal situation and the event of interest are compared to determine similarities and differences between the two. In the third step, the RCA teams seek to understand why the event occurred. The IHI recommends the RCA to "ask why five times." Direct and indirect causative factors that contributed to the event are identified in this step. Medical errors have various causes, and every possible cause should be identified and evaluated exclusively in this step. The fourth step involves linking what happened to the identified issues in the third step. The RCA team develops cause-effect relationships between identified causative factors and the actual event. In the fifth step, the RCA team develops and writes their recommendations geared towards preventing the recurrence of a similar event in future. The recommendations could be in the form of healthcare reforms, new policies, staff education, new technologies, or staffing changes. The dissemination phase is the sixth and last step in the RCA process. It involves writing a summary of the whole process and distributing it to the healthcare providers and associates. The Sentinel Event Root Cause Analysis The sentinel event was an intense and unexpected event involving a patient, Mr. B, who presented to the emergency department with excruciating hip pain, received treated but developed complications. The patient developed respiratory system and circulatory systems complications. After resuscitation attempts, he was referred to a better healthcare facility, where he was eventually diagnosed as brain dead. The family requested the withdrawal of the life support machine, and thus he died. Ideally, the patient should have been moderately sedated, and the necessary procedure carried out. He should have been monitored for respiratory and circulatory stability, gained the desired level of consciousness, and discharged to a stable patients' room. Later on, after fully recovering, he would have gone home. Hip injuries can be excruciating, but when correctly managed, they rarely cause death. The third step of an RCA process requires the identification of direct and indirect causes. Various factors could have caused the sentinel event. One possible cause would be sedation using Diazepam and hydromorphone. Diazepam is a benzodiazepine, and benzodiazepines are known to cause respiratory depression and cardiac arrhythmias (Webster & Karan, 2020). Hydromorphone is an opioid, and opioids are notorious for causing respiratory depression and premature deaths. A combination of an opioid and a benzodiazepine calls for close respiratory and cardiovascular monitoring. The combination also requires intubation which was not done for this patient. Respiratory monitoring was also not adequately done. The patient was discharged before gaining full consciousness against the hospital policy and emergency department discharge guidelines. The ecchymosis and swelling on the left leg calf were also not evaluated. It could be indicative of deep venous thrombosis. Possible thrombi could have dislodged and caused circulatory system compromise. After discharge, the patient was only monitored for blood pressure and pulse rate while other vital signs were left out. The respiratory rate and temperatures were not monitored. When the respiratory rate dropped at first, no corrective action was taken, and the response occurred only way too late when there was severe hypotension and low SpO2. The resuscitation attempts could not reverse brain death. The possible causes of brain death in this patient were respiratory and cardiovascular systems compromise and subsequent tissue hypo perfusion leading to brain death. In addition, emboli could have dislodged from the deep calf veins, causing respiratory or cardiovascular compromise. The nurses missed an opportunity to correct the compromise due to inadequate monitoring of the patient. Similar events could be prevented from occurring in the future through several interventions involving nurses, other healthcare professionals, and hospital management. Process Improvement Plan Proposal to Decrease the Likelihood of a Reoccurrence of the Scenario Outcome. The occurrences of the sentinel event call for the development of an improvement plan that will ensure the event does not reoccur in the future. Revision of the hospital policies should be done. A provision indicating that all patients under sedation in the emergency departments must be adequately monitored for respiratory compromise during and after procedures should be put in place (Harkens & Puller, 2018). Adequate training should also be given to nurses and doctors concerning managing patients with respiratory and cardiovascular compromise. Further, a closer analysis of the sentinel event reveals that there was a shortage of nursing staff. There were only two nurses despite the emergency department being a busy one. The hospital administration should employ enough nurses to help adequately monitor patients. An intervention integral in preventing the recurrence of the sentinel event is revising the sedation protocols. As webster and Karan (2020) argued, a benzodiazepine and an opioid should not be used in combination to sedate patients, and if used, the patient should be closely monitored. The above interventions will ensure the facility has adequate nursing staff for comprehensive patient monitoring, thereby preventing recurrence of a similar event. Applying Kurt Lewin's Theory to the Change Process Healthcare leaders have a huge role to play in change management. According to Cherry and Jacob (2019), change is inevitable and vital to any healthcare institution. Healthcare is very dynamic, and healthcare organizations must continuously evolve to adapt to these changes to maintain a high level of performance. Change can spread through working out loud or the ripple effect. Spread change is the process of copying/ implementing interventions that have been effective in a pilot study and utilizing them in other organizations or other organization sections (Cherry and Jacob, 2019). Kurt Lewin is a famous theorist renowned for his three-stage theory of change. The theory has been vastly used in change management. The three-stage theory outlines pertinent steps, namely, unfreezing, refreezing, and moving (Cherry, 2019; Hussain, 2018). The first stage, unfreezing, involves helping the staff visualize the flaws in the current situations and the need for change. The leader should use the sentinel event to create urgency and desire for change. Stressing on the need for change to the staff and other leaders would initiate action. The second stage involves giving the people a means to change. This would involve creating compatible interventions to change current practice and head towards achieving the desired objectives. Showing people that the sentinel event was preventable would be instrumental. Interventions presented are geared towards enhancing collaborative efforts in the change process. At this stage, healthcare leaders can motivate /facilitate change through reinforcements. Rewards can be presented to the providers who meet the set interventions and a fine to those who fail to follow them. The third stage, refreezing, involves cementing the change into the organizational culture. This third step ensures that such events do not occur in the organization in the future. It entails creating a culture of regularly training healthcare providers on patient emergency care. At this stage, for instance, the guidelines should also indicate that opioids and benzodiazepines should not be used in combination for sedation. If they are, the patient should be closely monitored for respiratory and cardiovascular compromise. All healthcare providers should be aware of the regulation and be able to execute it without failure. The hospital policies should also employ adequate nursing staff and ensure that an adequate number of nurses are on duty in the emergency department at any one moment. The patients on sedation should also be on cardiovascular and respiratory close monitoring until they gain the desired level of consciousness before being discharged. General Purpose of the Failure Mode and Effects Analysis (FMEA) P...