Root Cause Analysis: Improving performance for the long term

On Thursday afternoon after Mr. B, who was a 67-year old patient had arrived at the six-room emergency department of the sixty-bed rural hospital moaning and complaining, Nurse J who had received made a mistake that will eventually lead to the death of Mr B. Nurse J had completed the moderate sedation training module at the hospital. She had current ACLS certification and was an experienced critical care nurse. The manager’s annual clinical evaluations had reported that she was meeting the requirements and she did not have a history of neglecting patients in her care. 

Before administering sedation and any other medication, Nurse J should have known that the patients’ medical history indicated that he was currently using oxycodone and his body weight also will determine the amount of sedation to be administered (Payer, 2007) . The nurse should have alerted Dr T of the situation and then refrain from administering the additional 2mg of hydromorphone for controlling pain and 5mg diazepam for sedation at the same time. More so, Nurse J should have assigned one of the two nurses with her on duty to Mr B because of her busy engagement with the emergency care of the respiratory distress patient, which comprises evaluation, assessments and ordering of respiratory treatments, labs, CXR. 

The primary goal of root cause analysis is to learn from adverse occurrences and prevent them from occurring again in future (Latino, 2016) . The steps followed in root cause analysis include; defining the problem, collecting relevant data, determining the factors that led to the Sentinel problem, determining which factors are symptoms and which are the root causes, identify corrective measures and solutions to curtail the problem from occurring again in future and then the last phase is to implement the solution. The scenario problem was as a result of overdosing Mr B with hydromorphone for pain control and diazepam IVP for sedation that subsequently led to brain death of the patient and eventually leading to his death (Rooney, 2004) . The next step by the RCA is to collect relevant information from nurse J and the other staff on duty that day who were nurses RN and LPN, a secretary and one physician in the emergency department. The causative factors were negligence by the nurse, unacceptable drug selection and dose ranges, failure to review the patient’s recent medical history keenly. The contributing factors include the inadequacy of nurses. Hence nurse J was fully engaged and had to attend to more than five patients at the same time. 

Improvement plan should consider adding the number of nurses especially in emergency care of the respiratory distress patients, establish weekly training and review module for sedation and dose ranges, there should be close supervision for nurses in every department to prevent the reoccurrence (Payer, 2007) . Lewin’s change theory involves three phases; unfreezing, changing and then refreezing. According to Lewin, the entire process of change entails creating the notion that a change is required, then moving to the new level of behaviour and lastly, solidify the new behaviour. 

Failure modes and effects analysis(FMEA) is a systematic, active technique for analysing a process to identify where and how it might fail as well as to evaluate the impact of different failures in order to identify parts of the process that are most in need of change (Rooney, 2004) . FMEA emphasises on prevention which will reduce the risk of harm to both staff and the patients. FMEA will be helpful in preventing the reoccurrence of the sentinel scenario. The steps in FMEA include; selecting a process to evaluate with FMEA, analyzing using the system works better on processes that does not have too many sub-process instead of doing it on a complex process. FMEA will be critical in this problem because the hospital is only doing an evaluation on the single case of Mr. B. the next step is the recruitment of a multidisciplinary team that will comprise of the primary stakeholders. Step three involves getting the entire team to meet together and list all the steps necessary for FMEA. Every step should be numbered. 

Step four in FMEA will require the team to name the modes as well as the causes of the failures, including rare and minor factors. For each mode listed, identify all possible causes. Step five involves having the team assign a numeric value (RPN) for the likelihood of happening, detection and severity of each failure mode. Assigning RPN number will help the group to prioritise where to focus on as well as evaluating the avenues for improvement (Latino, 2016) . The next phase is evaluating the results, calculating the RPN for every mode of failure, severity and occurrence. Failure modes with the highest RPN are the ones for the team to consider as first improvement avenues while the ones with the lowest RPN are not likely to affect the overall process. 

FMEA Table 

Intervention testing will be based on the likelihood of the problem reoccurring, detection as well as severity. On the likelihood of occurrence, an evaluation of the causes will be undertaken and then modifying other processes that can contribute to the causes. The team should use FMEA to discuss and evaluate the changes being considered and calculate the RPN change if they are implemented. This enables the team to stimulate the specific change and then analyse it effects in a safe surrounding, before testing in a patient care. 

References 

Latino, R. (2016). Root cause Analysis: Improving performance for bottom-line results.

Payer, J. C. (2007). Current Practices in Sedation and analgesia for mechanically ventilated critically ill patients. The Journal of the American Society of Anaesthesiologists , 687 - 695.

Rooney, J. ,. (2004). Root cause Analysis for beginners. Quality progress , 45 - 56.