A root cause analysis is a structured procedure employed during the analysis of severe adverse events. In health care, the methodology is used as an error analysis tool. The key tenant of the root cause analysis is the identification of underlying glitches that elevate the probability of errors while evading the trap of converging on mistakes made by people. Therefore, the RCA will enable the health practitioners in identifying the latent and active errors within the healthcare systems (Charles et al., 2016). The root cause analysis process is divided into six core steps;
Identify what happened
The team members’ must try to accurately and completely try to describe what has happened. To ensure the process is smooth and yields the required results, the team should use a flow chart that will arrange the process; leading to the event in an orderly manner.
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Determine what should have happened
In this step, the team will determine what should have happened instead of the adverse event by using information from the first step.
Determine the causes
In this step, the team will now ascertain the factors that contributed to the event by focusing on the direct causes and contributory factors. In order to explore the cause of an event, one can sue a fishbone diagram (Kelly, Vottero, & Christie-McAuliffe, 2014).
Develop casual statements
In this step, the casual statement will be used in showing the relationship existing between the causes identified in the third step to the effects nd to the primary event identified in the first step. In this step, the contributory factors will be explored further to ascertain how they can lead to adverse outcomes among staff and patients.
Generate a list of recommended actions to prevent the re-occurrence of the event
In this team, all the measures that the team believes will prevent a future occurrence of the event are identified. The recommendations mostly fall under the following categories;
Educating staff
Developing new policies
Simplifying process. Using cognitive aids
Changing the physical plant
Standardizing equipment
Employing forcing functions which physically hinder users from making recurrent errors
Ensuring redundancy, for instance using backup systems or double checks
Updating or improving software
Writing a summary and sharing it
In this step, the team can engage the key players at the center to help in outlining the next steps in the process by using flowcharts.
A2. Apply the RCA Process to the Scenario
Mr. B’s death is because of cardiopulmonary arrest that stemmed from the sedation he received at the hospital. Too much sedation is the major causative factor for his death. Within 15 minutes, the nurse administered 4 milligrams of hydromorphone and 10 milligrams of diazepam. According to Kaye, Kaye & Urman (2014) hydromorphone has an onset time of 10-15 minutes and its peak time is 15-30 minutes while diazepam has an onset time of 1-5 minutes and peak time of 15-30 minutes. The hospital’s policy requires that a patient is placed on an ECG monitor yet Mr. B was not. This made it impossible to detect any heartbeat changes resulting from the sedation.
Moreover, sedation brings about a high risk of hypoxia yet Mr. B was not provided with supplemental oxygen. Mr. B did not have any nurse monitoring his conditions despite being placed on the pulse oximeter. Despite the LPN noticing the patient’s oxygen levels at 85%, she did not report it to the RN. This led to no corrective action being put into place.
The major cause of these errors included inadequate staffing at the health center. There was only one LPN and RN who also had to monitor three other patients in the ED and another patient who was being admitted . This is what contributed towards the sentinel event.
Process Improvement
The process improvement plan must begin with the formulation of a team from the various department within the health center. The team must conduct interviews from the personnel directly involved with the event. The team should also use various clinical documentation related to the event . The team will, therefore, outline a flow chart of what should have taken place. This will help in determining the root cause of the problem. The team should later create casual statements after reviewing the cause of the problem. This will outline the cause of the event, the effect of the causes and the link between the cause and the event. The final step is outlining recommendations that will be implemented to prevent further occurrence of the problem. Some of these include close monitoring of ECG and pulse oximeter and creation of sedation guidelines and checklist.
Lewin’s change model comprises of three crucial steps, unfreeze-change-freeze. According to Lewin’s change management model, it is based on the idea that understanding why change is necessary is crucial before engaging in any change process (DePew & Duncan, 2010). The unfreezing process requires one to re-examine various assumptions related to an individual and others so that the parties can understand why change is necessary. During the unfreezing process, the staff at the ER must be educated on the sentinel event and its causes so that they can have an idea as to why change is necessary. The team should, therefore, come up with better practices such as sedation safety checklist and staffing guidelines. The next step is implementing new practices during the unfreezing phase. The sew sedation guidelines will be used by the staff and the health care center will employ additional staff members in the ER. The management must ensure that it is involved throughout the implementation process to ensure it is successful. In the final stage is the freezing stage whereby the new changes are now incorporated throughout the entire health center.
Failure Mode and Effect Analysis
The FMEA is a tool that is employed when one wants to ascertain the potentiality of failures that may exist within a process or product. Failure modes represent the means through which a procedure can fail while effects are the methods by which these failures can bring about harmful outcomes, defects or waste (Institute for Health Improvement, 2004). Through FMEA, one will pinpoint, rank and limit the failure modes. FMEA consists of seven crucial steps;
Selection of evaluation process
The processes must not have many sub-processes, as it will make the FMEA process very large and complicated.
Recruiting of a team
The FMEA team must be multidisciplinary. All individuals involved in a particular process must be represented in the team. However, this does not mean that everyone must be part of the team.
Listing of all steps
All steps must be listed and numbered. This process is crucial as the team might be forced to organize many meetings to ensure that the process is fruitful.
Listing of failure modes and causes
The failure modes of each step must be thoroughly listed. This includes anything that could go wrong whether a minor or major step. The other step is the identification of the causes for all failure modes.
Assigning of Risk Priority Number
The RPN will allow the team to identify all areas by prioritizing the processes. The RPN helps in identifying the likelihood of occurrence, detection, and severity.
Evaluation of results
The RPN is calculated by multiplying the three scores attained for the possibility of incidence, detection, and severity numbered between 1 and 10.
Planning of improvement efforts
The failure modes bearing a much higher RPN value should be given top priority and thus the focus of improvement. Those bearing a low RPN do not have a huge impact though they should also be improved
FMEA Table
| Steps in the Improvement Plan Process | Failure Mode |
Likelihood of Occurrence (1–10) |
Likelihood of Detection (1–10) |
Severity (1–10) |
Risk Priority Number (RPN) |
| EXAMPLE: Doctor orders medication for pain prior to invasive procedure | Wrong medication selected | 3 | 5 | 5 | 75 |
| Failure to check patient outcomes by the nurses | Nurse negligence | 3 | 6 | 5 | 90 |
| Not supplying oxygen to patient during or after sedation | Nurse negligence | 4 | 5 | 5 | 100 |
| Forgetfulness by the nurse to hook patient to ECG | Nurse negligence | 2 | 6 | 8 | 140 |
| Inadequate staff to attend to patient needs | Management negligence | 3 | 6 | 6 | 108 |
| Total RPN (sum of all RPN’s) 394 |
- Testing Interventions
The best intervention testing procedure is using the Plan-Do-Study-Act (PDSA cycle). Through this procedure, the interventions will be tested through four steps, and the results evaluated the interventions are broken down into smaller steps and in case of improvement is required, it is implemented and later re-tested to check out whether it was successful (Sollecito,2018). To begin the test , data is gathered from the process. The data is used in detecting any problems and observations from the process. An analysis of the data is carried out and the results used in determining whether modifications are necessary. In case the process is not meeting the required standards, improvements are implemented .
Demonstration of Leadership
Promoting Quality Care
The formulation of policies can help improve the quality of care at a health center. This will ensure that nurse stick to procedures that can play a huge role in boosting patient safety. Moreover, using evidenced-based practices will help in promoting the quality of care
Improving Patient Outcomes
To improve the patient outcomes, nurses’ must ensure that all other health practitioners have an awareness of the expected patient outcomes. By helping the patient in recovering and enhancing their wellbeing, it will play a role in improving their overall patient outcomes.
Influencing Quality Improvement Policies
A nurse must support the use of evidence-based health practices. This is through promoting the use of such practices at the hospitals by showing other health professionals why they are essential . This can be through organizing various training programs to educate the other nurse of the recent and most effective practices.
Involving Professional Nurse in RCA and FMEA Process
Nurses have a vital role to play in the FMEA and RCA process. The nurses in most cases spend most of the time with patients as compared to the doctors. This indicates that nurses can easily point out most of the events that can cause adverse outcomes. By involving the nurse in the two processes, it will aid in much faster identification of the adverse events. Moreover, the nurses’ b will be largely involved in implementing the new policies and thus, having their sentiments during the formulation process is crucial.
References
Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., & Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient safety in surgery , 10 (1), 20.
DePew, R., & Duncan, G. (2010). Transitioning from LPN/VN to RN: Moving ahead in your career . Clifton Park, N.Y: Delmar.
Institute for Health Improvement. (2004) Failure modes and effects analysis. Retrieved on 31 March 2019, from http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx
Kaye, A. D., Kaye, A. M., & Urman, R. D. (2014). Essentials of Pharmacology for anesthesia, pain medicine, and critical care . Springer.
Kelly, P., Vottero, B. A., & Christie-McAuliffe, C. A. (2014). Introduction to quality and safety education for nurses: Core competencies . Springer
Sollecito, W (2018). Mclaughlin & Kaluzny's continuous quality improvement in health care . Jones & Bartlett Learning.
