My taskstream needs a revsion on section C2 on the presteps I need help writing this on this paper.
Running head: SYSTEM AND LEADERSHIP TASK 2 0
System and Leadership Task 2
Erica Gonzalez
Western Governors University
Student ID 00580183
System and Leadership Task 2
Complete RCA that takes into considerations causative factors, errors, and hazards
A 67-yr. old patient arrives to the ED on Thursday at 3:30 pm his name is Mr. B he is brought to the ED due to falling over his dog and losing his balance which caused him to fall. He is in severe pain and was brought in by his son and neighbor. Mr. B was then taken to the ED triage where they were assessing him so he could be seen by an ER physician. The 1st thing I would analyzed for this potential sentinel event is how much staff did the ED have, and was it staffed appropriately. Also, was there staffing ratio at the right core numbers or were they understaffed that day. The ED department was staffed with 1 RN, 1LPN, secretary, and a physician. After looking through the patient’s chart it was shown that Mr. B’s medication orders he received a large amount of medications in a small amount of time. It was shown that Mr. B received Diazepam 5 mg IV push at 1605, hydromorphone 2mg IV was given at 1615, pt. was still requiring medications so the physician ordered a 2nd dose of hydromorphone 2mg IV, and then a 2nd dose of diazepam 5mg IV was then given. This is a lot of medication in just a small amount of time causing a great deal of concern. I would then question the staff if they knew how fast the drug half-life was, and was the length of the medications given to Mr. B way to soon. The medication total outcome was 10mg of Diazepam, and Hydromorphone 4mg. This alone a lot of medication given to this patient that can cause major respiratory depression or arrest. Therefore, was the staff aware that they needed to do a pre-sedation checklist, and do a conscious sedation flow sheet to monitor the patient continuously while these drugs were given. There was also a RT in the hospital but was not utilized with this patient, no bag and mask were at bedside, so oxygen was on standby or and airway box. Another big concern was the patient was not even placed on oxygen, cardiac monitors, and the RN did not monitor the patient closely causing this lead to respiratory arrest. Mr. B should have been on full cardiac monitors, continuous pulse oximetry, and BP checked every 5 minutes, with oxygen placed on the patient, this would of lead us to early intervention of deterioration of pt.’s respiratory efforts. A major issue was the LPN did notify the RN, RT of physician about the patient’s saturations were alarming down to 85%. Due to lack of the RN and physician monitoring this patient coded at 1643, which a STAT code was called finding the patient to be with no pulse and not breathing. On a positive note, the staff did give good resuscitative efforts, but this all could have been prevented.
Process Improvement Plan
There should be a policy in place for patients who are given conscious sedation medications that a physician, RN, and RT will monitor the patient closely until fully away, and able to talk and drink.
There should be safety rounds done in the hospital every morning to determine if the ED needed more RN’s which they did that particular day.
Implement a pre-sedation check list for the hospital when a patient is going to have conscious sedation done, and be prepared to have your airway box, bag and mask, full cardiac monitors, continuous pulse ox, and BP monitored every 5 minutes with alarms audible.
Re-educating staff on medication management, and assessing their patient continuously.
Make sure that all RN’s, LPN’s have yearly education checkoffs with sedation medications, and complete an Elsevier testing to make sure they are competent.
ED educator needs to do annual checkoffs with staff on conscious sedation flow sheet to make sure they are competent.
B1. Implement Change Theory and Process improvement plan
Lewin defines his model on change theory a dynamic balance of forces working in opposing directions. The Change Theory has 3 notions which are the driving force, restraining forces, and equilibrium. Lewin also has stages of his theory which are unfreezing, change, and refreezing
(“Lewin’s Change Theory,” 2017). In the 1st stage I would like to speak with ED staff, and leadership team to discuss this sentinel event from ever occurring to another patient. This can be done by making sure they are monitoring and assessing patients as per policy, re-education on mediation administration to the nursing staff, and this will give good nursing practice. Therefore, it will help in decreasing any
resistance to the awareness of change, and making this the driving force (“Lewin’s Change Theory,” 2017). The 2nd stage is learning how to take care of these type of patients safely. Making sure the staff is competent, and comfortable with taking care of these type of patients. Making sure the policy is up to date, and going over with the staff on patient monitoring, and educating is the key to make this a successful event. In the final stage I would like to talk about the refreezing stage, my goal is that every single staff will feel competent in caring for this type of patients and with the new change taking effect. Process improvement is important with every day practice such as making sure you are being positive with your staff on how vital change is, and how it could save lives. The leadership team will be a vital role in this making sure that the staff will not divert back to their old way.
Failure Mode and Effects Analysis (FMEA)
C1. I will identify member of the FEMA team that will be included:
FMEA team consist of MD, patient, Nurse, LPN, RT, Nursing Leadership, and quality Director, risk director, house supervisor, pharmacy, educators.
C2. Discuss the Steps for Preparing for FMEA:
In getting ready for FEMA, I would include reviewing of the following, steps in the process, failure modes (“what could go wrong”), failure causes (“what would the failure happen”), and finally failure effects (“what would be the consequences of each failure”) (“Failure Modes and Effects (FMEA) Tool”, 2017). Once we put these steps in our following pt., and next recognize the steps in the process, we could see how long for a result. Pt’s who are sedated will always have their alarms on and audible with a nurse with them from the time the event starts until the patient is fully awake. The steps in caring for a pt under sedation with audible alarms on audible will be documented, and the RN, RT, and MD will remain with pt until the procedure is completed, this would make sure that early intervention and quickness will help any potential problems from occurring. A problematic concern to the new protocol is having a sedation team who is responsible for the alarms to be set and audible, and to make sure that a conscious sedation policy also includes that alarms are set with parameters, and is available for nursing. We could also make sure we give nurses more bonus shifts and this would make sure that this team will be protected, and incentive to join this team.
C3. Apply the 3 steps of the FMEA (severity, occurrence and detection)
The 3 steps of the FMEA are step 1 is failure mode (what went wrong), step 2 failure causes (why would failure happen) and step 3 is failure effects (What is the effects to the failure)
(“Failure Modes and Effects Analysis”).
| Failure mode | Failure causes | Likelihood of occurrence | Likelihood of detection 1-4 | Severity 1-4 | Actions to reduce occurrence of failure |
| Alarm communication mis-set | Inadequate training of monitor functions and capabilities | Mandatory education to staff | |||
| No standard for default settings | Lack of standard criteria for default settings | Make standards clear | |||
| Wrong configuration | Different monitors on different floors | Get like monitors | |||
| Alarm parameters mis-set |
| Put a hard stop on the alarms and re-educate on ordering | |||
| Alarm does not reach staff |
| Default all alarms on high volume setting | |||
| Staff deliberately ignore | History of false alarms | Staff monitoring | |||
| Alarm sound off or too low | Alarm setting hidden | Have biomed reconfigure | |||
| Staff to busy |
| Staff according to volume prediction as best you can | |||
| Inappropriate monitoring parameters | Lack of standard criteria for parameters | Re teach | |||
| Patient disconnected from monitor | Pt may have taken off leads or staff | Disconnect only as necessary | |||
| Staff confused about which alarm and which patient | Multiple alarms at the time in the ED | Monitor only as needed | |||
| Failure to recognize need for monitoring | Lack of standardized criteria for monitoring | Education to staff | |||
| Failure to provide complete monitoring order. Incomplete or absent orders | Lack of standardized criteria for monitor orders | Re teach MD on ordering | |||
| Order written by a MD who has not seen the pt. | MD has not assigned care to pt. | Re teach MD on ordering | |||
| Misplaced ECG leads | Medical staff and lack of education | Staff to be trained on placement of ECG leads |
C4. Testing the Intervention
We will make sure that the outcomes of the situations are best judged when planning changes are effective. We will get someone to do the Safety reports to check on the alarm settings and will let us know during a Safety meeting at least every 3 months. Another safety feature is to have the monitors already in place for the clinical alarms. The team will make sure the new changes will be re-evaluated and measured. The safety report meeting will relate to the clinical alarms and be directly told to the Quality department and then to the Medical improvement team who will look at each issues every 3 months. We will then have someone to QA in our department to make sure the alarm limits are set, and to see the trend. The senior leadership, director of the ED, ED physicians, ED educator, and charge nurses will observe every shift to make sure that the unit is complying.
Leadership in Nursing QA improvement
Nurses play an important role in QA improvement with patient safety, and quality patient care being the upmost importance. I would make sure that we have yearly competencies, computer modules with a test on Elsevier, and making sure we do the sedation log hands on so we as nurses are proficient. I would also make sure we do safety huddles for our department and to make sure we are up to date on what we need in the ED, or any issues arising. New nurses would have to be checked off, and will need to do conscious sedation on 3 patients with a preceptor, so they will feel comfortable on their own. The hospital can have safety fairs and update the hospital on patient safety and making sure that every patient be monitored appropriately. Nurses need to be a patient advocate. I would also have debriefings after each conscious sedation done, and ask staff what worked well and what did not, and how we can improve. Have the nurses be active in joining a committee such as preparing for Joint commission, and help quality improvement.
References
Failure Modes and Effects Analysis (FEMA). Institute for Healthcare Improvement (2004). http://www.ihi.org
Institute for Healthcare Improvement. (2017). Retrieved from http://www.ihi.org/resources/Pages/Tools/FailureModesandEffecrtsAnalysisTool.aspx
Nursing Theory. (2017). Retrieved from http://www.nursing-theory.org/theories-and-models/Lewin-Change-Theory.php
