Nursing Root Cause Analysis
Nursing Root Cause Analysis
Follow Task instructions: please review enclosed scenario and have detailed explanations for topics (A- C4) . Joint Commission is a useful website. Reference and title page must be included, however an Abstract isn’t necessary. Paper must be a minimum of 10 double spaced pages, not including reference. 4 pages total
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7 ask # .9-
Competencies: 734.3.1: Principles of Leadership – The graduate applies
principles of leadership to promote high-quality healthcare in a variety of settings
through the application of sound leadership principles.
734.3.2: Interdisciplinary Collaboration – The graduate applies theoretical
principles necessary for effective participation in an interdisciplinary team.
734.3.3: Quality and Patient Safety – The graduate applies quality improvement
processes intended to achieve optimal healthcare outcomes, contributing to and
supporting a culture of safety.
734.3.4: Healthcare Utilization and Finance – The graduate analyzes financial
implications related to healthcare delivery, reimbursement, access, and national
initiatives
Introduction:
Healthcare organizations accredited by the Joint Commission are
required to conduct a root cause analysis (RCA) in response to any
sentinel event such as the one described below. Once the cause is
identified and a plan of action established, it is useful to conduct a
failure mode and effects analysis (FMEA) to reduce the likelihood that
a process would fail. As a member of the healthcare team in the
hospital described in this scenario, you have been selected as a
member of the team investigating the incident.
Scenario:
Scenario:
It is 3:30 pm. on a Thursday and Mr. B, a 67-year-old patient, arrives at the six-
room emergency department (ED) of a sixty-bed rural hospital. He has been brought
to the hospital by his son and neighbor. At this time, Mr. B is moaning and
complaining of severe pain to his (L) leg and hip area. He states he lost his balance
and fell after tripping over his dog.
Mr. B was admitted to the triage room where his vital signs were B/P 120/80, HR-88
(regular), T-98.6, R-32, and his weight was recorded at 175 pounds. Mr. B. states
that he has no known allergies and no previous falls. He states, “My hip area and leg
hurt really bad. I have never had anything like this before.” Patient rates pain at ten
out of ten on the numerical verbal pain scale. He appears to be in moderate distress.
His (L) leg appears shortened with swelling (edema in the calf), ecchymosis, and
limited range of motion (ROM). Mr. B’s leg is stabilized and then he is further
evaluated and discharged from triage to the emergency department (ED) patient
room. He is admitted by Nurse J. The admitting nurse finds that Mr. B has a history
of impaired glucose tolerance and prostate cancer. At Mr. B’s last visit with his
primary care physician, laboratory data revealed elevated cholesterol and lipids. Mr.
B’s current medications are atorvastatin and oxycodone for chronic back pain. After
the nurse completes Mr. B’s assessment, Nurse J informs the ED physician of
admission findings and the ED physician proceeds to examine Mr. B.
Staffing on this day consists of two nurses (one RN and one LPN), one secretary, and
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TUK#
2-
Competencies: 734,3.7: Principles of Leadership – The graduate applies
principles of leadership to promote high-quality healthcare in a variety of settings
through the application of sound leadership principles,
734.3.2: Interdisciplinary Collaboration – The graduate applies theoretical
principles necessary for effective participation in an interdisciplinary team.
734.3,3: Quality and Patient Safety – The graduate applies quality improvement
processes intended to achieve optimal healthcare outcomes, contributing to and
supporting a culture of safety.
734.3.4: Healthcare Utilization and Finance – The graduate analyzes financial
implications related to healthcare delivery, reimbursement, access, and national
initiatives
Introduction:
Healthcare organizations accredited by the Joint Commission are
required to conduct a root cause analysis (RCA) in response to any
sentinel event such as the one described below, Once the cause is
identified and a plan of action established, it is useful to conduct a
failure mode and effects analysis (FMEA) to reduce the likelihood that
a process would fail. As a member of the healthcare team in the
hospital described in this scenario, you have been selected as a
member of the team investigating the incident.
Scenario:
Scenario:
-+
It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient, arrives at the sixroom emergency department (ED) of a sixty-bed rural hospital. He has been brought
to the hospital by his son and neighbor. At this time, Mr. B is moaning and
complaining of severe pain to his (L) leg and hip area. He states he lost his balance
and fell after tripping over his dog.
Mr. B was admitted to the triage room where his vital signs were BlP tz1l91, HR-88
(regular), T-98.6, R-32, and his weight was recorded at 175 pounds. Mr. B. states
that he has no known allergies and no previous falls. He states, “My hip area and leg
hurt really bad, I have never had anything like this before.” Patient rates pain at ten
out of ten on the numerical verbal pain scale. He appears to be in moderate distress.
His (L) leg appears shortened with swelling (edema in the calf), ecchymosis, and
limited range of motion (ROM). Mr. B’s leg is stabilized and then he is further
evaluated and discharged from triage to the emergency department (ED) patient
room. He is admitted by Nurse l. The admitting nurse finds that Mr, B has a history
of impaired glucose tolerance and prostate cancer. At Mr. B’s last visit with his
primary care physician, laboratory data revealed elevated cholesterol and lipids. Mr.
B’s current medications are atorvastatin and oxycodone for chronic back pain. After
the nurse completes Mr. B’s assessment, Nurse J informs the ED physician of
admission findings and the ED physician proceeds to examine Mr. B.
Staffing on this day consists of two nurses (one RN and one LPN), one secretary, and
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one emergency department physician. Respiratory therapy is in-house and available
as needed. At the time of Mr. B’s arrival, the ED staff is caring for two other patients.
One patient is a 43-year-old female complaining of a throbbing headache. The
patlent rates current pain at four out of ten on numerical verbal pain scale. The
patient states that she has a history of migraines. She received treatment, remains
stable, and discharge is pending. The second patient is an eight-year-old boy being
evaluated for possible appendicitis. Laboratory results are pending for this patient.
Both of these patients were examined, evaluated, and cared for by the ED physician
and are awaiting further treatment or orders.
After evaluation of Mr. B, Dr. T, the ED physician, writes the order for Nurse J to
administer diazepam 5 mg IVP to Mr. B. The medication diazepam is administered
IVP at 4:05 p.m. After five minutes, the diazepam appears to have had no effect on
Mr. B, and Dr. T instructs Nurse J to administer hydromorphone 2 mg IVP. The
medication (hydromorphone) is administered IVP at 4:15 p,m. After five minutes, Dr.
T is still not satisfied with the level of sedation Mr. B has achieved and instructs
Nurse J to administer another 2 mg of hydromorphone IVP and an additional 5 mg of
diazepam IVP. The physician’s goal is for the patient to achieve skeletal muscle
relaxation from the diazepam, which will aid in the manual manipulation, relocation,
and alignment of Mr. B’s hip. The hydromorphone IVP was administered to achieve
pain control and sedation. After reviewing the patient’s medical history, Dr. T notes
that the patient’s weight and current regular use of oxycodone appear to be making
it more difficult to sedate Mr. B.
Finally at4:25, the patient appears to be sedated and the successful reduction of his
(L) hip takes place. The patient appears to have tolerated the procedure and remains
sedated. He is not currently on any supplemental oxygen. The procedure concludes
at4:30 p.m. and Mr. B is resting without indications of discomfort and distress. At
this time, the ED receives an emergency dispatch call alerting the emergency
department that the emergency rescue unit paramedics are en route with a 75-yearold patient in acute respiratory distress. Nurse J places Mr. B on an automatic blood
pressure machine programmed to monitor his B/P every five minutes and a pulse
oximeter. At this time Nurse J leaves his room. The nurse allows Mr. B’s son to sit
with him as he is being monitored via the blood pressure monitor. At 4:35, Mr. B’s
B/P is LLO/62 and his 02 sat is92o/o. He remains without supplemental oxygen and
his ECG and respirations are not monitored,
Nurse I and the LPN on duty have received the emergency transport patient. They
are also in the process of discharging the other two patients. Meanwhile, the ED
lobby has become congested with new incoming patients. At this time, Mr. B’s 02
saturation alarm is heard and shows “low 02 saturation” (currently showing a sat of
85o/o). The LPN enters Mr. B’s room briefly and resets the alarm and repeats the B/P
reading.
Nurse J is now fully engaged with the emergency care of the respiratory distress
patient, which includes assessments, evaluation, and the ordering respiratory
treatments, CXR, labs, etc.
At 4:43, Mr. B’s son comes out of the room and informs the nurse that the “monitor
is alarming.” When Nurse J enters the room, the blood pressure machine shows Mr.
B’s B/P reading is 58/30 and the 02 sat is 79o/o. The patient is not breathing and no
palpable pulse can be detected.
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A STAT CODE is called and the son is escorted to the waiting room. The code team
arrives and begins resuscitative efforts. When connected to the cardiac monitor, Mr.
B is found to be in ventricular fibrillation. CPR begins immediately by the RN, and Mr.
B is intubated, He is defibrillated and reversal agents, IV fluids, and vasopressors are
administered. After 30 minutes of interventions, the ECG returns to a normal sinus
rhythm with a pulse and a B/P of LLO/7O. The patient is not breathing on his own
and is fully dependent on the ventilator. The patient’s pupils are fixed and dilated. He
has no spontaneous movements and does not respond to noxious stimuli. Air
transport is called and, upon the family’s wishes, the patient is transferred to a
tertiary facility for advanced care,
Seven days later, the receiving hospital informed the rural hospital that EEG’s had
determined brain death in Mr. B. The family had requested life-support be removed,
and Mr. B subsequently died.
Additional information: The hospital where Mr. B. was originally seen and treated had
a moderate sedation/analgesia (“conscious sedation”) policy that requires that the
patient remains on continuous B/P, ECG, and pulse oximeter throughout the
procedure and until the patient meets specific discharge criteria (i.e., fully awake,
VSS, no N/V, and able to void), All practitioners who perform moderate sedation
must first successfully complete the hospital’s moderate sedation training module.
The training module includes drug selection as well as acceptable dose ranges.
Additional (backup) staff was available on the day of the incident. Nurse J had
completed the moderate sedation module. Nurse J had current ACLS certification and
was an experienced critical care nurse. Nurse J’s prior annual clinical evaluations by
the manager demonstrated that the nurse was “meeting requirements.” Nurse J did
not have a history of negligent patient care. Sufficient equipment was available and
in working order in the ED on this day.
Task:
a root cause analysis (RCA) that takes into consideration causative
factors, errors, and/or hazards that led to the sentinel event (this patient’s
outcome).
A. Complete
B.
Discuss a process improvement plan that would decrease the likelihood of a
reoccurrence of the outcome of the scenario.
1. Discuss a change theory that could be used to implement the process
improvement plan developed in B.
failure mode and effects analysis (FMEA) to project the likelihood that
the process improvement plan you suggest would not fail.
1. Identify the members of the interdisciplinary team who will be included in
the FMEA,
2. Discuss steps for preparing for the FMEA.
3. Apply the three steps of the FMEA (severity, occurrence, and detection) to
the process improvement plan created in part B,
4. Explain how you would test the interventions from the process
improvement plan from part B to improve care in a similar situation.
C. Use a
Note:You are not expected to carry out the full FMEA, but you should
explain each step, and how you would apply it to your process
improvement plan,
D.
Discuss how the professional nurse may function as a leader in promoting
quality care and influencing quality improvement activities.
E. When you use sources to support ideas and elements in a paper or project,
provide acknowledgement of source information for any content that is
quoted, paraphrased or summarized. Acknowledgement of source information
includes in-text citation noting specifically where in the submission the source
is used and a corresponding reference, which includes:
o Author
o
r
r
Date
Title
Location of information (e.9., publisher, iournal, or website URL)
Note: The use of APA citation style is encouraged but is not required for this task.
Evaluators will offer feedback on the acknowledgement of source information but not
with regard to conformity with APA or other citation style. For tips on using APA
style, please refer to the APA Resources web link found under General
Information/APA Guidelines in the left-hand panel in TaskStream,
Note; No more than a combined total of 3oo/o of a submission can be directly quoted
or closely paraphrased from outside sources, even if cited correctly.
p Evatuation
Method
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