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Wgu Organizational Leadership Task 2

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Organizational Systems & Quality Leadership Task 2
Candace Grant

Organizational Systems & Quality Leadership Task 2

According to Joint Commission standards a RCA is conducted after a sentinel event occurs in a facility. This gives the facility (and Joint Commission) the ability to determine the causative factors contributing to the event, thus giving them the ability to change those factors to decrease the likelihood of occurring again. The RCA answers the who, where, what, why, and how in the event. After the RCA has answered those questions, they can begin to put in place an action plan and begin a failure mode and effects analysis (FMEA) to prevent it from repeating (Tools, 2016).
A list of events helps us organize the causative factors contributing to the sentinel event.
At 3:30pm- Mr. B was brought to the ER for left hip pain rated at 10. Vital signs are stable
At 4:05pm- Nurse J administered Diazepam 5mg IVP
At 4:10pm- Since the Diazepam had no effect Dr. T orders 2mg of Hydromorphone
At 4:15pm- 2mg of Hydromorphone was administered IVP.
At 4:20pm- Mr. B is given another 2mg of hydromorphone, and diazepam 5mg IVP.
At 4:25pm- Mr. B appears to be sedated and reduction of his (L) hip takes place. The procedure concludes at 4:30pm. No distress is noted and patient is placed on monitor for blood pressure to be taken every 5 minutes along with pulse oximeter. No supplemental oxygen or ECG leads placed on Mr. B. Mr. B’s son is the only one left in the room after the procedure
At 4:35pm- Mr. B vitals are BP 110/62, O2 sat is 92%. The ER is becoming busy
After the ER becomes busy the alarm is heard and Mr. B’s Oxygen sat is 85%, the LPN silences and does not apply supplemental oxygen also does not inform nurse or MD of finding.
At 4:43 - Mr. B’s son comes out of room and informs the nurse that the monitor is alarming. Mr. B’s B/P is 58/80 and his O2 is 79%. The patient has no palpable pulse and is not breathing. A STAT code is called and the son is taken to the waiting room. The code team arrives and initiates the Code protocol.
At 5:13pm-The ECG returns to a normal sinus rhythm Mr. B’s B/P was 110/70. He is completely dependent on the ventilator, his pupils are fixed and dilated. No spontaneous movement The family asked for the patient to be removed to another facility for further care.
Sentinel Event- Seven Days later Mr. B has died. The family had requested that life-support be removed after brain death had been determined by EEG’s.
Once a team is put together the RCA should be started. The team should be made up of of the Supervisor/ Nursing coordinator, Director of nursing, risk management, and the department manager. They should set up discussions with all the staff that was involved the day the sentinel event happened. A complete chart appraisal should be conducted by team. The policies on conscious sedation, staffing of department, and standardized work should be reviewed. When the cause is identified a corrective action plan should be initiated. The corrective action plan will allow a series of projects can be put in place to help produce or modify polices as needed. The new or changed polices should be put into education models to teach to current and new staff as needed. One thing to keep in mind during this process is to involve the staff in an unbiased and matter of fact manner, so no one feels blame is put on them.
In the scenario presented for Mr. B many factors played a role in his eventual demise. The RCA would reveal-
1. The nurse does not question any orders given by Dr. T.
2. Dr. T did not notice the patient’s medical history of chronic pain until after several doses of medication were ordered and given by the nurse.
3. No staff member followed the procedure for conscious sedation
4. The patient was not monitored correctly- no vital signs during the procedure and no ECG, or pulse ox during or after the procedure.
5. The LPN entered the room and shut off the alarm, but did not place patient on oxygen.
6. LPN did not inform RN or MD of patient’s status change.
7. No one informed supervisor or management of increased acuity and patient load coming into the ER. Also no additional staff was called in even though they were available. Administration /Organizational cause factors include the lack of staffing for acuity and increased patient load.
RCA Findings: Errors and/or Hazards that led to the sentinel event-
1. The conscious sedation protocol was not followed.
2. The patient was not monitored properly during the procedure. He had no monitoring during the procedure, when the protocol calls for continuous B/P, ECG, and pulse ox throughout the procedure. Nurse J had been through the training module and should have stayed with the patient until he met the discharge criteria.
3. Respiratory Therapy was not informed of procedure being done.
4. Poor communication between nurses- The LPN did not notify the RN or MD when she went into the room and shut off the alarm. She also did not place oxygen on the patient when his oxygen sat was 85%.
5. No communication with supervisor or management when acuity and patient load increased. The nurse had to leave Mr. B’s room to attend to another patient. Being over sedated and unmonitored led to his respiratory distress.
6. The physician did not call for the patient to get transferred to a higher level of care. The scenario stated that the family requested it. Change Theory- Change is usually difficult and can be hard to accept and implement. To help with this transition Kurt Lewin’s change theory can be used. “Kurt Lewin theorized a three-stage model of change that is known as the unfreezing-change-refreeze model that requires prior learning to be rejected and replaced” (change theory, 2016). Once the causative factors have been identified, it’s important to relay the information in a matter of fact non-blaming manner. After discussing the factors that lead to the event (unfreezing stage) it’s also very important to make those involved with the adjustment feel as if they are a part of implementing the change (change stage). In the scenario this would include having Nurse J and the LPN help with a new conscious sedation policy. Then we will implement the improvement plan.
A process improvement plan that we can follow to decrease the likelihood of a reoccurrence would include:
1. All staff following the conscious sedation protocol 100% of the time. A team will be formed to review the protocol to ensure best practice guidelines are in use. All staff will be educated/reeducated. All staff must complete a module and a class with a practice sedation scenario within 90 days of RCA report.
2. A “time out” shall occur before procedure to review the protocol involving MD, nursing staff, and respiratory therapy.
3. Another team will be formed to evaluate communication. Education will be provided on reportable events to/ from the LPN to RN and nurse to MD. A policy shall be written to provide staff with guidelines on documentation of communication.
4. Management will publish and follow safe nurse to patient ratios for emergency rooms.
5. A policy shall be instituted immediately to ensure communication between departments and supervisors/management. If there is no staff available for incoming patients, and there is risk of harm to the patients, the hospital shall be placed on diversion to avoid more patients coming in.
6. Management shall share the RCA findings with the emergency room staff. 30 days after implementing the change theories, feedback should be collected to ensure improved patient safety. The feedback should include new processes and staff input for improvement. Also, include audits from management to ensure the new processes are being implemented.
During the first 90 days, feedback from staff, along with the continuing audits, should be documented and reviewed by all involved with the goal of improved patient safety. At the 90- day mark the management team should re-evaluate the policies and protocols that have been put in place to see if any changes need to take place. These steps will help to “re-freeze” the new process.
The RCA we conducted in this scenario is a reaction to a sentinel event. It is conducted retroactively to find the failings of the system or systems that led to the event. A failure mode and affects analysis (FMEA) is the opposite. Its purpose is prevention. It looks at the process and assesses the process for risks of failures and adverse events, and corrects them. The Institute for Healthcare Improvement has tools that can be utilized to evaluate the process. One of the tools available is the risk priority number (RNP) which evaluates the impact of the process and interventions, and tract the improvement long term (Tools, 2016).
The steps for preparing for the FMEA- In order to conduct a FMEA the organization must form a team that includes staff from every department that is affected. For the scenario involving Mr. B, we would need the nurse, MD, respiratory therapist, pharmacist, supervisor and/or management, and someone from the legal department. These individuals need to be made aware of the study at hand- the conscious sedation protocol. There needs to be a review of the current situation so all involved know what the analysis reveal. A good way to keep this step in the process organized is using flow charts describing each part of the process. For our scenario it could be a flow chart of the current conscious sedation policy. It is important that everyone on the team is in agreement at this point in the FMEA process to avoid confusion or conflict during the analysis. They need to collect data on conscious sedation protocol from their hospital, outside policies from other hospitals that have had good success, and best practice guidelines for the procedure. They should research other clinical practice guidelines pertaining to the procedure and bring that research to the team meeting. The team should appoint a lead person to structure the meeting and to keep the team focused and on point. Once the team has been assembled, using the RCA, they should make a list of failure modes and the causes. They need to make sure to list all possible causes for each failure mode. For example, in this scenario – Medication- wrong medication prepared, wrong dose prepared (Improvement Stories, 2016).
In order to apply the three steps of the FMEA (severity, occurrence, and detection) we would assign a RPN to each step in the failure mode listed, using a range from 1 to 10. For example, Wrong medication prepared -Occurrence - (5), Detection – (6), Severity- (9). Each step measures something different. Occurrence measures the likelihood a failure mode shall occur (1 is very unlikely to occur and 10 being very likely to occur), Detection measures the likelihood a failure mode is detected should it occur (1 meaning it is very likely to be detected and 10 meaning very unlikely to be detected), and Severity measures the severity of the failure mode (1 is no effect, 10 means death occurs immediately). The scores are multiplied and the failure mode with the highest RPN will be the one the team focuses on to ensure patient safety. For this scenario the team multiplies 5x6x9=270. So for the failure mode of Wrong medication prepared it equals 270.
Once we have the RPN the team can formulate an improvement plan. For the Wrong medication prepared failure mode of Occurrence (rated 5 so somewhat likely to occur) would include scanning medication when pulled from the Pyxis, Scan patient to ensure proper medication for patient and proper orders, Check the Five Rights- right patient, right medication, right dose, right time, right route (Five Rights, 2016). For Detection (rated “6”- so somewhat difficult to detect), we can look at the reasons the error was not detected (MD looked at history after giving orders, or nurse did not question drug choice), and reeducate staff, and encourage open communication to question orders. Severity (9 death occur at a later date) intervention would include make all resources available to all staff to prevent further errors and lesson severity of errors. For example, catching an error immediately to lesson consequences to patient.
Now that we have interventions from the process improvement plan, we need to test them. During the testing phase, all data collected should be well documented. This includes both successes and failures from the interventions. Any unanticipated problems that arise should also be documented. The tem should meet to conduct an analysis of the testing phase, making note of success, and listing ways to possible change interventions to try again. Sometimes changes may not mean success, so it is an ongoing process to test, evaluate, analyze, and then communicate. The team should make sure to then communicate any changes to the staff and management. So for example from our process improvement plan number one- we can check to find out if all staff have completed the module and education. If they have not, we need to discuss with them any barriers that may be preventing them from completing that intervention, and make changes if needed.
Nurses can function as leaders in providing quality care in many ways. Nurses have extensive contact with patients, and their families. They are sometimes the only advocate a patient has. As nurses we are responsible to ensure patient safety and do no harm. Our patients and families trust us with their lives. We can use evidence base practices to improve care and safety in our hospital/community. We must make ensure the systems we have in place provide a successful and safe way to provide that care. Joining a team and being an active participate on boards or forums gives us the voice to communicate potential problems, and hopefully fix them before they reach a patient. We are the eyes and ears of the hospital.

Institute for Healthcare Improvement. (2016). Retrieved from

Institute for Healthcare Improvement. (2016). Retrieved from

Department of Defense Patient Safety Center. (2012, 12/26). Failure Mode and Effects Analysis.
Retrieved from

Change theory (2016). Retrieved June 2, 2016 from

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...Organizational Systems and Quality Leadership Task 2 Jill Riccobono Western Governors University Organizational Systems and Quality Leadership Task 2 A. Root Cause Analysis A root cause analysis (RCA) looks at an event and considers what happened, why it happened what will be done to prevent it from happening again and how will we know that the changes made will improve the safety of the system. It takes into consideration causative factors, errors and hazards that led to a sentinel event. In this case it was a patient’s death. RCA should not look to place blame on people, but rather processes that need to be improved. The first step in a RCA is to identify what happened. In the scenario, presented in this task, the patient was over sedated and subsequently died. Step two is to identify why this happened. There were preventable causative factors, or errors, that led to this sentinel event. The hospital’s conscious sedation policy requires that the patient remains on continuous BP, ECG, and pulse oximeter throughout the procedure and there was no mention that this was performed at all throughout the procedure. It was not until after the procedure that Mr. B was placed on continuous BP and pulse oximeter, and at that time, the patient was left in the room, with only a family member while Nurse J attended to another patient. When the alarm is heard that the patient has low O2 sats, the LPN, enters the room and resets the alarm and repeats the B/P reading. His oxygen......

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