Nursing Root Cause Analysis

Introduction

Root cause analysis (RCA) is a well-detailed platform that allows analysis of adverse events that lead to an avoidable occurrence that causes a patient to either experience permanent harm, severe temporary harm or ultimate death (“Root cause analysis,” 2014). Root cause analysis provides a platform that allows healthcare institutions to make a thorough self-evaluation that enables them to identify where possible mistakes or negligence may occur. Moreover, it is important to appreciate that the RCA is used to identify both active and latent errors. An active error occurs when health care workers interact with the complex institution system. A latent error, on the other hand, occurs when causal factors are hidden deep with the health care system ((“Root cause analysis,” 2014). This paper utilizes RCA in order to come up with an analysis of the case of a patient Mr. B, where the aim is to identify the root cause of his death.

Event Being Investigated

Occurrences at the hospital is investigated. A patient by the name of Mr. B visited a sixty-bed rural hospital after suffering from a fall, leaving him with injuries to his left leg and hip that lead to his death.

Short Description of What Happened

This is a case where a patient Mr. B was rushed to the hospital by his son and a neighbor after suffering a fall that left his left leg and hip in severe pain. On arrival, all the staff present was a registered nurse (RN), a licensed practical nurse (LPN) and an emergency department physician. The patient was taken through all the necessary evaluations before any procedures to rectify his left leg and hip were done. Dr. T struggled to sedate the patient with the administered hydromorphone 2mg IVP, the diazepam 5 mg IVP, which seemed not to have an effect. Dr. T instructed nurse J to administer more hydromorphone 2mg IVP to attain sedation in addition to diazepam 5 mg IVP. The additional dosages fall within the accepted levels. These actions attained the doctor’s desired result and soon the patient’s leg and hip were treated. After the procedure, Mr. B seemed okay and comfortable and was placed under automatic blood pressure (BP) machine to monitor his BP and a pulse meter. However, other cases made nurse J leave Mr. B to go and attend to other patients. Over the time, the oxygen level and pulse rate of the patient remained unobserved, and the patient eventually suffered from ventricular fibrillation, a factor that ultimately led to his death.

Root Cause Analysis

It is evident that Mr. B’s death was caused by the effects of reduced BP (58/30) and low O2 saturation (79). This is indicated by the tertiary facility for advanced care that Mr. B was flown. They informed the rural hospital that electroencephalogram (EEG) confirmed that Mr. B had suffered a brain death. Having identified this, the goal is to analyze the occurrences and identify how Mr. B came to suffer from a ventricular fibrillation.

Causative Factors

One of the causes that led to Mr. B suffering from ventricular fibrillation is the lack of close monitoring. The BP and O2 saturation continued to decline while nurse J and the LPN were not keen enough to notice. A contributing reason for this occurrence was the excessive workload nurse J and the LPN were exposed to. We are informed that nurse J was taking care of two other patients: an 8-year-old child suspected of suffering from appendicitis and a 43-year-old female suffering from a severe headache. Moreover, even after a successive procedure on Mr. B, nurse J and the LPN had to rush to discharge the other two patients in addition to admitting the emergency team patient.

This is a clear demonstration of how occupied the two present nurses were during the time Mr. B was not being looked after to monitor his pulse rate, BP and oxygen saturation level. The excessive workload made them forget to check these levels in a sequenced manner that could have identified that Mr. B situation was indeed deteriorating. The result was the fact that even with low BP and O2 saturation Mr. B remained without supplemental oxygen. Moreover, his ECG and respiration remained unmonitored. Nurse J and LPN were so overwhelmed that after nurse J saw Mr. B being in a stable condition she prioritized other patients who seemed more unstable, such as the patient that was brought in by the emergency team.

Errors

One conspicuous error is evident in the manner in which the LPN handled Mr. B’s O2 saturation alarm. The LPN came in briefly and reset the alarm and was not keen on identifying that the O2 saturation levels were low (85%). The nurses had to be called by Mr. B’s son, and this should not be the case at any given time. Nurses should ensure that all patients receive relevant monitoring time. The LPN ought to have read the O2 and BP readings and taken them to nurse J for clarification on what needed to be done. This is a huge error committed by the LNP. On the other hand, nurse J made an error of assuming that because Mr. B was stable after the procedure, he did not deserve a close monitoring like other patients did. When nurse J finally came, it was too late as both the oxygen saturation and BP were very low leading to the patient suffering from ventricular fibrillation.

Workload Process Improvement Plan

Improved Nurse-Patient Ratio

The major reason behind Mr. B’s worsening condition in the lack of close attention by the nurses who were on duty. His oxygen saturation and BP levels continued to drop, and the nurses were not aware of it. Moreover, the patient continued to be off oxygen support and this ultimately led to the patient’s unstable condition.

To remedy this situation, there is a need to ensure that the rural hospital has enough nurses at all times. The excess workload is one of the reasons Mr. B was neglected, as the two nurses tried to negotiate their way across the hospital to attend to different patients with different needs. Having the right number of nurses and LPNs will ensure that all the patients have equal access to nursing help and, therefore, any emergency cases will be dealt with accordingly.

Improved Technology Integration

Another evident problem in the rural hospital was the “unprofessional” behavior demonstrated by not identifying the levels of O2 and BP. Therefore, in order to ensure that this does not happen again, there is a need to ensure that there is a compulsory form that any nurse should fill once he or she has visited any patient. Besides, registered nurses and LPNs need to have a gadget that connects them directly and captures both the visuals and audio. This will ensure that LNP will always be in a position to receive advice on what to do based on the prevailing situation the patient faces. Having the right number of nurses and providing a platform, where the registered nurse can guide the local practical nurse, will provide patients with relevant help in a timelier manner. A close contact enabled by gadgets will ensure that the registered nurse advice is accessible to the LPN through a live feed, thus enabling the LPN to handle different issues in the hospital more diligently.

Change Theory that Could Be Used to Implement the Process Improvement Plan

Lewin’s Change Theory

The rural hospital needs to change the way things are run and come up with a new way whereby nurses are in the right number to ensure that all patients are better looked after. To do this, there is a need to adopt relevant changes that will enable both the hospital and the healthcare workers to work in a more patient-centric manner. Lewin’s change theory presents a good reference point for change to the rural hospital since it needs both systemic and behavioral changes. It is best known for providing a reference point when it comes to changes in human systems (Masters, 2012), and the rural hospital is one of them. The three stages of Lewin’s change theory are unfreezing, movement, and refreezing. They present a supportive platform through which the rural hospital can foster change.

Unfreezing

This is the stage where the intention is to find all relevant methods that can be utilized to influence people or the whole system to let go of their current counterproductive status quo (Masters, 2012). One way of unfreezing the current norm is through a meeting with the healthcare workers and elaborating the need to change the norm. A reference to the case at hand can provide a good rationale why the need for change in the hospital is relevant.

Movement

In this stage, the intention is to influence the change of duty allocation to ensure more nurses are added per shift to minimize the workload per nurse. Besides, there is a need to train healthcare workers particularly the RNs and their LPNs on how to use life feed gadgets that will improve their one-on-one contact within the hospital. The management is, therefore, expected to come up with necessary realignments that will help the hospital move away from the current way of operation. This will lead to a shift towards a more improved patient- nurse ratio and a more improved coordination among the healthcare workers.

Refreezing

This entails absorption of the new norm as the standard way of doing things within the concerned organization (Masters, 2012). In the case at hand, the rural hospital’s management needs to develop relevant and supportive policies for the new norm that will see to it that the new improved coordination and patient-nurse ratio become a formal and standard way of operations in the rural hospital.

Failure Mode and Effects Analysis (FMEA)

Members of the Interdisciplinary Team

• The rural hospital manager (chairperson)
• Myself (coordinator)
• Two worker’s representative of one gender each (members)
• Human resource manager (workforce advisor)
• Financial controller (financial advisor)
• Technical advisor

Steps for Preparing for the FMEA

Assemble The Interdisciplinary Team – Here the intention is to come up with a team comprised of relevant specialists in the field and familiar with the case at hand.

Identifying the Scope of the FMEA- To ensure that relevance is upheld, there is a need to create boundaries regarding what the FMEA intends to do.

Identifying the Function of the Scope of FMEA- This entails identifying the functions of the process or the plan that is being evaluated.

Ways in Which Failures Can Occur- At this stage the aim is to identify all avenues that failure can manifest itself in the plan or the process at hand.

Failure Consequence Correlation- At this stage, the intention is to identify the effect each failure can have on the general plan or process.

Verification of Degree of Effect of Each Failure- This is also known as the severity rating, whereby each failure’s impact is analyzed to identify the failure mode that would pose the greatest danger to the success of the plan or the process at hand.

Root Causes of the Failure- Here the intention is to correlate each failure with its possible causes.

Failure Occurrence Rate- Here the aim is to demonstrate the likelihood of a failure occurring.

Current Process Controls- This stage identifies the existing controls that will ensure that failures do not occur in the plan.

Control Detention Rating- Here the test is on the effectiveness of the prevailing controls when it comes to prevention of the failure occurring or detecting them before they caused any harm to the system or the customer.

Recommended Actions- This forms the last phase of an FMEA whereby relevant actions are proposed to ensure a more efficient plan is upheld. (American Society For Quality, n.d.).

The Three Steps of the FMEA Application

Degree Of Severity	Probability Of Occurrence	Ability To Detect
Patient being at risk of negligence	poor nurse-patient ratio	The current control will detect when there is a low nurse-patient ratio
Patient’s welfare being at risk	Human error	The new live feed gadget improves the coordination among the health words thus reducing human error.
Patients being at risk misdiagnosis in terms of prescription	Current control of live feed gadget minimizes such occurrence.

Testing the Interventions

The patient survey presents the most valid way of testing the ‘Workload Process Improvement Plan’. The plan aims at ensuring that patients receive the best health care in the rural hospital by performing a random sample survey on their experience with nursing care in the hospital. This will provide helpful insights into the strengths and weaknesses of the plan.

How the Professional Nurses May Function as Leaders in Promoting Quality Care and Influencing Quality Improvement Activities

Quality in nursing is upheld by utilizing evidence-based approach while dealing with various patients’ medical problems. This is possible because utilizing this approach ensure that the action taken meets the current expectations and demands in the field of medicine (Ellis, 2010). Therefore, a professional nurse can be a leader in promoting quality care and influencing quality care activities by agitating and influencing other health care workers to utilize the evidence-based approach in their line of work. This will ensure that any action or decision taken by the healthcare workers delivers maximum utility to the concerned patient.

Conclusion

It is evident that RCA plays a crucial role in ensuring that hospitals are better placed in preventing reoccurrence of adverse events. Besides, RCA is an essential tool that sheds light on areas where improvement or total overhaul is needed to ensure a more efficient way of caring for the patient is obtained. Moreover, FMEA works to strengthen the RCA-based solution by proving insights in the area where the proposed solution can fail and the impact the failure might have on the entire solution plan. Moreover, the process of combining both insights from RCA and FMEA bring forth a solution plan that enables a health care institution create a solution plan that is not only evidence based but also one that revolutionize its way of operations.

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