Organizational Systems and Quality Leadership

1459 words | 5 page(s)

Healthcare organizations require a continued focus on the challenges of achieving high quality patient care on a continuous basis. This process requires a greater understanding of the challenges of achieving care and treatment for patients who face the risk of compromises in patient care quality as a result of nursing-related activities. These concerns are real and timely in today’s complex healthcare environments, particularly when any number of concerns could lead to complexities in quality of care and treatment. It is important to identify the resources that are required to ensure that patient care is not compromised in any way throughout the process of delivery. When adverse events occur, however, patients must be evaluated appropriately in order to determine the cause of these events and whether or not all appropriate actions were taken. This process supports the continued engagement of nurses in order to determine the events that have taken place. Modifying a protocol that is unsuccessful requires a high level of attention and support to ensure that future opportunities are effective and appropriate for patients to ensure that their lives are not compromised by the actions that are conducted.

Root Cause Analysis
With the example provided, the root cause analysis is necessary because the patient died while under the care of the critical nurse. In this case, the steps of the root cause analysis address the following concerns: the patient’s leg pain and edema were not properly assessed, which was a contributing factor to his current condition. His pain and edema should have been evaluated very closely and without delays. However, the treatment of two additional patients exacerbated his problem because his situation was not given the proper attention that it deserved. This is an error because his care was compromised during evaluation and his condition quickly deteriorated as a result. Furthermore, the patient was not provided with supplemental oxygen and did not receive ECG and respiration monitoring in a timely manner that contributed to the outcome. Both events were hazardous to the patient’s already compromised condition. In this context, the patient has not thoroughly been assessed for his condition, and therefore, he is at serious risk. The root cause analysis also requires a causal tree, for which this example supports an understanding of the patient’s plight in the immediate aftermath of his admission to the emergency department. Furthermore, the decision table might be effective in this case in order to prevent future errors from reoccurring in similar cases, including any hazards or other events that led to the outcomes of this case (Williams, 2001).

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In order to prevent reoccurrences in the future, it is important to apply specific theoretical principles to avoid similar outcomes. By using a change theory, specifically Social Cognitive Theory, nurses are able to recognize the challenges that they face as they attempt to modify existing procedures to better accommodate patient needs more rapidly (Battilana & Casciaro, 2012). In the example scenario, Social Cognitive Theory would enable the improvement of activities and procedures taking place in the ED that will favor improved patient outcomes and a reduced risk of serious adverse events. However, proper attention must be paid in order for these outcomes to occur. Individual nurses, under Social Cognitive Theory, should self-reflect on the necessary changes in thought that could have been made to prevent the further complications in the patient that led to death. They must also examine their social surroundings at the time of the mishap to determine whether social structures need reexamination such that this problem will not occur again. When social structures allowed nurses and doctors to overlook factors that may indicate problems with a patient, the structures themselves should be reevaluated so that they are minimizing these sorts of mistakes.

The failure mode and effects analysis (FMEA) is essential to this case as a means of establishing new perspectives regarding the failures that have occurred within a specific framework that could be prevented in future settings (ASQ, 2014). By removing the failure modes from the situation (ASQ, 2014), such as adequate staffing to address all urgent patients in a timely manner, there is less risk of failure within the system as a whole. The effects analysis will support an evaluation of the consequences, such as death of the patient in the case scenario (ASQ, 2014). Pre-steps to FMEA must also be conducted that determine the failure that has occurred, why it occurred, the factors that were responsible, and how to prevent the situation from happening again. This requires data to be gathered and evaluated, such as patient charts as well as any reports that have been filed regarding the incident. Furthermore, the pre-step process must also identify current policies regarding how to manage these events.

The three parts of an FMEA are severity, occurrence, and detection, which can be determined using a ten-step process. To begin, first, the key process steps must be listed, which in this case include the primary patient coming in and being examined, the two other patients being examined, and the patient developing further complications. Second, the potential failure modes are described for each step. Here, the patient was not given proper attention, including recognition of leg pain and edema. Third, the effects of this failure mode are listed which include the patient not receiving supplementary oxygen or an ECG. The fourth step involves rating the severity of these effects, which in this case would be very high given the outcome. Fifth, identify the causes of failure which was the lack of attention. Sixth, the controls in place to detect such issues. The primary control in place was the attending nurse who became occupied with other patient concerns. Seventh, determine risk priority numbers, which involve multiplying severity, occurrence, and detection. This number would likely be moderate for this case given the great severity, hopefully low occurrence, and low detection number. The eighth step is the sorting of RPN numbers to determine the most critical issues and where to focus future efforts. This step will likely show that more attention needs to be paid to individual cases. Ninth, Assign specific actions for responsible individuals, which in this case is primarily the attending nurse detecting the leg pain and edema. Tenth, rescore the occurrence and detection, which would, of course, bring the RPN number down significantly.

This case is severe because it clearly demonstrates the weaknesses in protocol that limit the capacity of nurses to provide attentive and high quality care for their patients. Furthermore, the occurrence is how the patient’s condition was addressed during his time in the emergency department. Nurses must be able to balance their duties effectively in the emergency department to avoid compromising patients’ lives. If this is not achievable, then other alternatives must be considered. It is expected that improved nursing care quality in the emergency department will be achieved through a comprehensive detection system that will identify any possible cracks in the current system that may impact patient care outcomes and the risks that are observed within the system. This process will also enable nurses to evaluate their current procedures and to determine if additional frameworks are required to facilitate improved quality of care in this scenario and in future events. When errors do occur, they must be promptly identified and addressed quickly to educate regarding these errors to prevent future repeats of the same errors. It is the job of attending nurses to help ensure that symptoms that present are discovered and recorded, which in this case may have prevented the further complications.

Nurses working in the emergency department must be effectively prepared to manage a wide variety of scenarios that have a significant impact on patient care quality and treatment. Nurses are responsible for adhering to established protocols in a timely manner and for detecting any possible errors or limitations with current policies that could impact patient care quality. These scenarios demonstrate the importance of new perspectives in evaluating patients in the emergency department and in providing comprehensive care and treatment to avoid serious risks, such as severe adverse events and even death. These factors play an important role in shaping outcomes for patients and in providing a framework for success that will contribute to a successful recovery for these patients over the long term. These scenarios provide an opportunity to explore different insights regarding established procedures as a method of managing patient care quality in a manner that is consistent with established protocols that govern nurses in the emergency department setting.

  • ASQ (2014). Failure mode effects analysis (FMEA). Retrieved from http://asq.org/
  • Battilana, J., & Casciaro, T. (2012). Change agents, networks, and institutions: A contingency theory of organizational change. Academy of Management Journal, 55(2), 381-398.
  • Williams, P.M. (2001). Techniques for root cause analysis. Proceedings (Baylor University Medical Center), 14(2), 154-157.

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