The general purpose of conducting a root cause analysis, commonly abbreviated RCA, is to establish the exact cause of a problem, thus why it occurred in the first place. This helps doctors and other practitioners establish how and why a patient is experiencing a certain problem (Okes, 2009). Therefore, the RCA makes the diagnosis process possible and ensures accuracy through the elimination of many scenarios that could mislead the process of diagnosis. According to the Institute for Health Improvement (IHI), the six steps used to conduct an RCA are; identifying what happened, determining what should have happened, determining causes, development of causal statements, generation of a list of recommended actions to prevent the recurrence of the event and finally writing a summary and sharing it.
Identifying what happened entails setting up a team, which is responsible for the organization and provision of clarity in the event using flowcharts. Determining what should have happened is the second step, which entails the team's efforts towards determining what would have happened in the event the conditions were ideal. The third step, determining causes, entails the establishment of the direct causes as well as contributing factors, thus most apparent and indirect causes respectively. The fourth step entails linking the cause identified in step three to its effects and the back to step one. The fifth and sixth steps entail determining recommendations or solutions for the event at hand and organizing data on how to go about the issue, which is shared in a bid to drive improvement.
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The contributing factors that led to the sentinel event outcome in the scenario provided can be described based on the various steps of the RCA. The causative factor of the pain in Mr B’s hip and leg areas in the fall he sustained when he lost balance and fell. The contributing factors include a history of impaired glucose tolerance and prostate cancer, which may have attributed to the loss of balance and the pain experienced respectively. The elevated cholesterol and lipids levels could have also been contributing factors that resulted in the inability for the sedatives to relieve him of his pain and sedate him, thus the use of higher dosages of both diazepam and hydromorphone. A process improvement plan that would decrease the possibility of a reoccurrence of the scenario outcome would be to ensure the patient’s impaired glucose tolerance is corrected as well as the elevated cholesterol and lipid levels.
In applying Lewin’s three phases of the change theory on the human side of change, the proposed improvement plan could be undertaken in a certain way. This would entail, in the first phases of unfreezing, establishing what the causes the patient’s impaired glucose tolerance is corrected as well as the elevated cholesterol and lipid levels (Swansburg & Swansburg, 2002). The second phase, transition, would entail establishing the necessary steps towards correcting the patient’s impaired glucose tolerance is corrected as well as the elevated cholesterol and lipid levels. Finally, the third phases, Freeze would entail ensuring the patient’s impaired glucose tolerance is corrected as well as the elevated cholesterol and lipid levels are maintained at a level that does not negatively influence the administration of the necessary medication (Swansburg & Swansburg, 2002).
The general purpose of the failure mode and effects analysis process commonly abbreviated FMEA is to establish potential failures that may be present within a particular design of a product or process (Press, 2003). Therefore, in the event an RCA is conducted and does not result in the establishment of the exact cause, thus how and why, a problem occurs in a patient, FMEA, can be conducted to establish the potential failures in the RCA process. The FMEA process, according to Institute for Health Improvement (IHI), consists of four steps namely, identification of possible failures and effects, determining severity, gauging the likelihood of occurrence and finally, failure detection.
There are various ways of testing the interventions from the process improvement plan from part B to improve care. Among them is to ensure that the tests are done in connection with the RCA rather than simply basing the tests on the patient’s past health issues. Similarly, tests should be conducted more on the causative factors rather than the contributing ones since the contributing ones may lead further ways to a proper diagnosis. In the event of administering any form of pain medication, proper tests should be done in a bid to establish the most effective medication to use depending on where a patient is experiencing pain to avoid administration of the wrong medication, which will prolong the patient’s experience of pain. Also, the right quantities should be established based on the patient’s pain level, which would prevent the need to administer more medication since the patient’s pain will not be relieved as soon as it needs be.
Professional nurses can competently demonstrate leadership in various areas through certain things. For instance, in the area of promoting quality care, professional nurses can ensure they are taking proper tests to establish the proper medication to provide patients with. In the area of improving patient outcome, professional nurses can competently demonstrate leadership by ensuring they check on a patient’s progress for improvement practices and administration of changes where needed. The involvement of the professional nurse in the RCA and FMEA processes reveals leadership qualities since the processes involve team making, which require great leadership qualities to run and control. Similarly, having a team that includes professional nurses builds the confidence of patients, which also demonstrates leadership qualities of competency.
References
Okes, D. (2009). Root cause analysis: The core of problem solving and corrective action . Milwaukee, Wis: ASQ Quality Press.
Press, D. (2003). Guidelines for Failure Mode and Effects Analysis (FMEA), for Automotive, Aerospace, and General Manufacturing Industries . CRC Press.
Swansburg, R. C., & Swansburg, R. J. (2002). Introduction to management and leadership for nurse managers . Boston: Jones and Bartlett.
