Cause Analysis
The procedure starts with collecting information concerning the incident. Further, the information needs to be analyzed, and the final step is to obtain solutions to the errors, which are found to ensure that the reoccurrence of the same error does not take place concurrently. Thus, after assembling the team, they should begin the RCA process. This should start with the patient and the clinical staff embroiled in the error to find the cause of the problem. Afterward the team members should work hard to come up with the most appropriate solution to ensure that the error does not take place concurrently. In the case, Mr. B is presented to a rural health facility that only has a six bed Emergency Department, in a very critical condition as a result of a fall. However, while seeking for care, Mr. B came across various challenges that caused his death. One of the drawbacks was that the ED was adequately staffed. It had only one registered nurse, licensed practical nurse, as well as one physician. The hospital also had other patients, though they were not in critical conditions. However, during his stay in the hospital, a patient was brought in with respiratory problems that required immediate attention by the registered nurse and a medical doctor. Further, in the ED, nurses are continually subject to disruptions, due to the need to multi-task as a result of inadequate support systems. As such, the nurses were affected by distracting the ongoing developments with Mr. B. As such the nurse was not able to anticipate the urgent need for additional help because she was overwhelmed but continued to proceed as if there was no help required. As such, this presented an issue of the culture of safety. Nonetheless, it never appeared that there was any form of organizational culture of safety, as well as communication between the clinical staff members.
Improvement Plan
The main purpose of the improvement plan is to decrease the likelihood of a reoccurrence of the outcome of the scenario. As such by requiring that the staff of the emergency department to reassess the actions of the day, it was vital to ensure that dialogue was in place and mainly created to initiate a stronger motivation that may seek out better and newer ways to handle the patients who may be in need of sedation. Nevertheless, the three-stage process of transitioning through the change starts by a successful change process ( Doak, Doak, Fischhoff, Brewer, Downs, J& United States, 2011) . Hence, it is necessary to understand that change must first take place and this is where the motivation for the change process starts. Individuals must assist to re-examine the assumptions concerning the relationship with others. This is a stage that is regarded as unfreezing. After the uncertainty that is experienced in the unfreezing stage has taken place them change will begin to take place. Hence, the clinical staff will begin to support the new growth of the department.
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B1. Change Theory
The change theory has three major concepts or diving forces that push the change in the direction of what causes the changes to take place in an organization. As such, they facilitate the change, which are the driving forces that pus the direction that cause change; hence facilitate the change due to the fact that they push the change in the direction. On the other hand there are the restraining forces that hinder change because they push individuals in the opposite direction. The equilibrium is considered as a state of being, especially when driving forces as well as equal restraining forces and no changes to take place.
As such, by recognizing all these steps, it is easy to plan and implement change. By considering the change process that has distinct stages, it is easy to prepare for what is anticipated and then make a plan to assist in managing the change. However, it must be understood that motivation for the change process is to ensure that it is generated before it occurs. According to the change theory used, the third stage is the most crucial because it takes place after the organization has already recognized the obstacles to managing the change process. As such, Lewin's third stage of change provides that there should be a feedback system to enable the staff to take part in the change process considering their knowledge and level of education. With this in mind, the changes will be applied all the time and will also be incorporated into the normal daily operations of the Emergency Department. However, when the changes are not implemented as required, especially on a daily basis and anchored to the culture of the Emergency Department, most likely the freezing state will not take place; hence rendering the staff to get caught up in the transition state. As such, the employees will not be certain of how the operations are being conducted and whether there exists an inconsistency for the policies as well as procedures that are put in place to be followed.
FMEA
FMEA refers to step by step process that is deployed to identify all the possible failures that are most likely to take place in the design. It has been used in the healthcare industry as a tool to recognize various areas that are prone to failure to ensure that any form of harm os avoided or sentinel events before they take place. However, in this case, it is quite unfortunate that the FMEA may not alter the outcome. However, it will be a proactive approach that can be used to develop a new policy as well as procedures in the manner in which sedation cases are managed especially in an emergency environment. The tool will be used to examine the new protocol required for sedation methods coupled with the staffing protocols that are linked to monitoring ( Finkelman & Kenner, 2009) . Nonetheless, the evaluation will not take place before the actual implementation; hence it will be applied to evaluate the effects of the current or existing protocols. Thus, the processes that will need assessments and improved in the case of Mr. B will be moderate sedation policy as well as its specifics to the requirements of staff especially at the time of the procedures coupled with the recovery period.
C1. Members of the Interdisciplinary Team
The members of the interdisciplinary team will comprise of the emergency room physician, the director of the respiratory therapy, the pharmacist, the ED nursing director, risk manager, the head administrator and one or two certified nurses from the ED that perform sedation procedure. Others to be included are the head of anesthesiology. The team will require regular meetings to make them committed to offering support during the implementation stage.
C2. Pre-Steps
To ensure that FMEA becomes a success, it is necessary to follow various steps. These involve identifying the participant, discussing the possible concerns relating to the medical staff, and finally, the processes issues and the environment of the occurrences that may take place in the ED.
C4. Interventions
It is apparent that with the unfortunate case involving Mr. B., it will be the responsibility of the interdisciplinary team to start the interventions, which will be necessary to be aligned with the new management of the moderate sedation patients. The main goal will be to improve safety and to be able to remove the detrimental occurrences. There will be a mandatory test to be conducted at the start of the procedure.
D. Key Role of Nurses
The professional nurses will be able to play a major role in the hospital quality improvement since they are the primary caregivers ( Grossmann, Institute of Medicine (U.S.)., & National Academy of Engineering, 2011) . Besides, they will be vital to improving the processes that will involve care provision. Thus, the role of the professional nurse will be to conduct interdisciplinary procedures to ensure that organizational goals are met. On the other hand, the nurse manager will be responsible for communicating and operational zing the organization’s goals as well as processes. Finally, it is the responsibility of the bedside nurse to conduct the protocols as well as standards of care that are demonstrated by evidence to improve the quality of care.
References
Doak, L. G., Doak, C. C., Fischhoff, B., Brewer, N. T., Downs, J. S., & United States. (2011). Communicating risks and benefits: An evidence-based user's guide . Silver Spring, MD: U.S. Dept. of Health and Human Services, Food and Drug Administration.
Finkelman, A. W., & Kenner, C. (2009). Professional nursing: Competencies for quality leadership . Sudbury, Mass: Jones and Bartlett.
Grossmann, C., Institute of Medicine (U.S.)., & National Academy of Engineering. (2011). Engineering a learning healthcare system: A look at the future : workshop summary . Washington, D.C: National Academies Press.
Norman, C. L., Nola, T. W., Moen, R., Provost, L. P., Nolan, K. M., & Langley, G. J. (2013). The improvement guide: A practical approach to enhancing organizational performance . San Francisco, Calif: Jossey-Bass.
Rahschulte, T. (2007). Understanding how to change: An inductive determination of how agents of state government plan, lead, and sustain change . Ph. D. Regent University 2007
