Root Cause analysis
Causative Factors.
Different factors led to the patient being brain dead. The Use of too much sedative to sedate Mr. B could have affected his mental functions. Furthermore, Dr. T. used diazepam to help the patient’s muscles relax so as to undertake repositioning of his hip. In this process, Mr. B was fully sedated. The patient’s previous medical conditions combined with the medication administered to him during the treatment at the hospital were the cause of death.
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Errors
Upon admission, the patient explained that his injuries had occurred after he tripped over his dog and fell. Before administering any medication to the patient, nurse J failed to note that the patient was currently regularly taking Oxycodone. Due to this error, the patient failed to react to the use of diazepam in sedation. Furthermore, Dr. T. also recommended the use of diazepam without consideration of the patient’s weight. Furthermore, since the hospital’s regulations explicitly noted that a nurse would undertake monitoring of a patient’s condition during sedation until such a time that the patient became conscious from the sedation. When nurse J. left Mr. B before he recovered consciousness, this counted as negligence by the nurse.
B. Process Improvement Plan
To prevent reoccurrence of the outcome of the above case, The rural hospital needs to institute different changes. First, before conducting any medical procedures, the hospital should undertake a thorough investigation of any previous medical conditions may have which may affect the treatment process. Furthermore, the hospital should also conduct a thorough check of any medication that a patient may currently be taking which could have an impact on the treatment process. Furthermore, the hospital should also purchase monitoring machines capable of continuous monitoring a patient’s condition continuously. For example, the hospital did not monitor Mr. B’s respiration after the operation to relocate his hip. Furthermore, the automatic blood pressure machine that Nurse J. uses to monitor the patient’s blood pressure only records the pressure after five minutes.
This process improvement plan would allow the hospital to identify any conditions or medication that pose a risk during the process of medication. Furthermore, continuous monitoring of the patient’s condition after the treatment has received treatment would allow for faster emergency response. The nurses would receive immediate notification of deteriorating conditions of patients.
Change Theory
The hospital should apply Grundy’s types of change theory. This theory classifies the type of change experienced in an organization into three categories, that is, smooth incremental change, bumpy incremental change and discontinuous change. The best change concept to implement in this hospital is the smooth incremental theory. Under this theory, the change in the organization would be continuous. Here, the hospital would adapt new technology to keep pace with the changes in technology in the medical profession. Furthermore, the continuous change would allow the hospital to stay updated with the best methods of treating patients with different conditions.
In improving the monitoring process of patient conditions, Grundy’s change theory would allow the organization to purchase new equipment for monitoring. This would involve a incremental process and would be bumpy as the transition would be sudden. The process would involve a sudden change to the use of new monitoring equipment. Likewise, Grundy’s theory change would be instrumental in bringing about smooth incremental changes. For example, in applying the theory, the nurses would gradually become more efficient at their work performance.
C. failure mode and effects analysis (FMEA)
Preparing the FMEA shall involve some steps. The first process is function or process step. Here, the analyst will prepare an outline of a given function and analysis. The second step is the type of failure. In this step, the analyst provides a description of the situation that has gone wrong. The third phase is the description of the severity of the error to the patient. In the fourth step, the analyst investigates the potential causes of the situation. Subsequently, in the sixth step, the analyst shall estimate the likelihood of the reoccurrence of the failure. Finally, in the sixth step, the analyst shall devise a method of detecting the failure. The analyst shall also specify the difficulties that exist in the detection process.
In instituting the changes in the organization, the hospital shall mainly use severity, occurrence and detection. Detection is a major step in this planned change. The purchase of equipment to monitor the changes in a patient’s condition constitute the detection step. The occurrence step will involve analysis of records to determine how often the changes occur. The hospital will keep a record of the failures detected in the treatment. These will be important in estimating the frequency of occurrence of these failures. Severity measures the seriousness of a failure in the system. For example, the failure in Mr. B’s treatment was very severe because it led to the death of the patient. To measure the severity of the failure, the hospital will record the effect of the failure on the patient. Some failure results in more severe consequences than others and demand to be attended to more urgently.
Several factors will contribute to the success of the FMEA in this situation. Preparing an outline of the situation under investigation will generate a good understanding of the situation and this will derive the process of change implemented. Describing the failure adequately shall ensure that one understands all aspects of the failure. Severity analysis determines the intensity of the change measures to be taken. Describing the potential causes of the error make it easy for one to identify th likelihood of such an occurrence reoccurring in the future as one can easily identify the symptoms. The FMEA shall, therefore, be an effective tool for use in avoiding a reoccurrence of the situation in the future.
Members of the Interdisciplinary team
The hospital will undertake failure mode and effects analysis (FMEA) to predict the possible reoccurrence of such an incidence in the future (Woods, 2015). To undertake the FMEA, different members of the hospitals will be involved. Some of the participants in this process include the hospital’s management, the doctors at the hospital and the nurses, the emergency response team, patients at the hospital and representatives of the surrounding community. The hospital management will provide guidance on the steps in the process of change. The doctors and nurses will be involved in the actual process of implementing the change. Patients will be directly affected by the changes as they will receive better healthcare services from the hospital. Finally, the community surrounding the hospital will participate in the change process by identifying aspects in which the hospital should implement change.
Pre-steps
In preparing for undertaking the FMEA, the hospital will undertake three steps. The first step will involve assembling of a team to implement the FMEA. The team will involve representatives from all groups affected by the change process. The second step will involve determining the scope of the FMEA. This step will be instrumental in determining the level of change that the group will undertake. A wider scope of the FMEA would mean that the hospital anticipates to undertake more changes in its operations. Finally, the last step will involve the identification of the format that the FMEA would follow. This format would be essential in guiding the hospital through the FMEA.
The role of the professional nurse as a leader.
Promotion of quality care in the provision of medical services is an essential process. “Nurses have key roles to play as hospitals continue their quest for higher quality and better patient safety” (Needleman, & Hassmiller, 2009). As leaders in the service delivery of hospitals, nurse plays a fundamental role in the quality of service provision. The nurses interact directly with the patients and are responsible for giving medication for the patients. Furthermore, it is the nurses that monitor the conditions of the patients and report these to the doctor. In this capacity, the nurses should ensure that they report accurately to the doctor. The patients then receive quality recommendations that guarantee their comfort. For example, if a nurse fails to report that a certain patient is experiencing pain, then the doctor would not prescribe painkillers to the patient. The patient would experience discomfort because of the failure of the nurse in reporting.
- Needleman, J., & Hassmiller, S. (2009). The role of nurses in improving hospital quality and efficiency: real-world results. Health Affairs, 28(4), w625-w633.
- Woods, D. (2015). A Failure Mode and Effects Analysis (FMEA) from Operating Room Setup to Incision for Living Donor Liver Transplantation. In 143rd APHA Annual Meeting and Exposition (October 31-November 4, 2015). APHA.
