C489 Task 2 RCA and FMEA Essay

Buy ready-to-submit essays. No Plagiarism Guarantee

Note: Every paper is crafted by human writers to ensure authenticity and originality.

C489 Task 2 RCA and FMEA Essay

StuDocu L

Harvard University
Indiana Wesleyan University
George Washington University
University of Chicago
Villanova University
University of Central Florida
The University of Texas at Arlington
University of the People
University of Rhode Island
University of Georgia
University of California Los Angeles
Southern New Hampshire University
Grand Canyon University

Courses

Popular
    school as a community of care (D090)
    Health Assessment (NSG 351)
    Professional Presence and Influence (D024)
    General Biology II (BSC 2011)
    Fundamentals of diverse learners (D096)
    Anatomy And Physiology (BIOL 2201)
    nursing (nur 601)
    Assessing Impact on Student Learning (D093)
    Biology (BIOL 1700)
    English (ENGL0101)
    Business Management (QHT1)
    Organic Chemistry II (CHEM 273)
    Applied Humanities (HUM200)
    Communications and Networking (CS 2204)
    Organizational Theory and Behavior (BUS 5113)
Trending
    Pharmacology (N180)
    American Politics and US Constitution (C963)
    Physio-Patho Basis of Adv Nsg (NU 545)
    Careers In Nutrition (NUTR 170)
    Improving Quality of Care and Patient Safety (4020)
    pharmacology (NUR307)
    English Literacy Skills (ENGL 0113)
    Financial Accounting (ACG2021)
    Ethical & Ani Welfare Issues (VM 513)
    Introduction to Pharmacology (NUR115)
    Organizational System (C489)
    Fundamentals (VN100)
    Medsurg 1 (NSG3037)
    Fostering Student Engagement (ELM-357-0501)
    Mathematics for Elementary Teachers I (MAT-150)
Newest
    Business and Society (proctored course) (BUS 3306)
    Mathematics for Life Scientists (LS 30B)
    historia del arte (mundo artistico)
    mental health (NUR2010)
    College Writing I (WRIT 105)
    Applied Macroeconomics. (ECON 101)
    General Humanities I (To 1400). (GNHU 201)
    General Chemistry II (Lecture + Lab) (CHEM-1412)
    Advanced Pharmacology for Nurse Practitioners (NURS 5334)
     Nursing Care of Adults II (NURS 4628 )
    Nclex (206)
    Abnormal Psychology (PSYCH 223)
    Introduction To Professional Nursing (NUR 3160)
    Calculus I (MATH 030)
    Contracts (LAW 0612)

Documents

Popular
    315-HW6 sol - fall 2015 homework 6 solutions
    Request for Approval to Conduct Research rev2017 Final c626 t2
    Rashid Ahmed DA
    PhysioEx Exercise 12 Activity 4
    Weight Mass Student - Answers for gizmo wieght and mass description.
    Chapter 5 - Summary Give Me Liberty!: an American History
    Case Study Chapter 41 - GERD
    Lactase Enzyme Introductory Bio II Lab
    ATI System Disorder Template Heart Failure
    BANA 2082 - Chapter 1.5
    Chapter 06 Aplia Assignment
    Physio Ex Exercise 8 Activity 3 - Assessing Pepsin Digestion of Proteins
    OB Exam 1 Study Guide (The Bible)
    Final Exams - Selection of my best coursework
    Ch 1-7 - Lecture notes CH 1-7
Trending
    Psychology 101 Notes
    Docuri
    Module 8 question 3 Consider the following statement: ANCSA led to economic benefits for white Alaskans as well as for Natives. Is this conclusion consistent with the evidence presented in this learning block? Answer Yes or No, and then explain your choic
    Ati nursing care of children rn 2019 proctored exam
    Essentials of Psychiatric Mental Health Nursing 8e Morgan, Townsend
    Med Surg 2 Study Guide Answer Key
    Eng quiz - It is related to grammar, brainstorming quizzes, thesis statement quizzes etc
    Module 8 question 2 Consider the following statement: ANCSA was a fair settlement for Alaska Natives. Is this conclusion consistent with the evidence presented in this learning block? Answer Yes or No, and then explain your choice in one or two sentences.
    Physio Ex Exercise 1 Activity 4
    C489 Task 2 Original - Passed with no revisions
    CJ 120 Module 8 project 3
    394177421 how to File 1096 1099a 1099oid to Pay Utility Bills
    NHA CCMA Practice Test Questions and Answers
    (8) Making freebase with ammonia cracksmokers
    Heparin drip calculation reference
Newest
    Tera Técnica Y Posición 45
    Tarea Huesos Cabeza 2
    419801523 7mo artes Plasticas Completo
    Kami Export - BLHS Clubs LIST
    Psych Exam 1 Quests - Test bank questions
    Quest Exam 3
    Kami Export - Xavier Copeland - Treble Clef 3
    Psy Exam 4 (Test) - Test bank questions
    Kami Export - Xavier Copeland - South Carolina Business Brochure Final
    Kami Export - MW The Lady or the Tiger
    Kami Export - Civil Rights Leaders
    Kami Export - Xavier Copeland - Brown vs Board of Education
    Kami Export - Xavier Copeland - Big Bang SE redshift mod
    CHEM 1412 Exam 2 Topics
    Mark klimek lecture notes

Books

The Profession of Dietetics
Business Law: Text and Cases
Give Me Liberty!: an American History
Psychology
Visualizing the Environment
Interpersonal Communication
The Ideological Origins of the American Revolution
Campbell Biology
Biological Science
Fundamentals of Digital Literacy
Saunders Comprehensive Review for the Nclex-Rn Examination
Leerboek HRM
Organic Chemistry
Brunner and Suddarth's Textbook of Medical-Surgical Nursing
The Remains of the Day 

C489 Task 2 RCA and FMEA
C489 Organizational Systems and Quality Leadership Task 2 RCA and FMEA

C489 Organizational Systems and Quality Leadership
C489 SAT1 TASK 1 passed no revisions!!
Organizational Systems And Quality Leadership Task 2
Task 1 C489 - Task 1 C489
RCA and FMEA - no revisions
US vs Switzerland - no revisions
TASK 1 Nursing- Quality Indicators
C489- SAT Task 1: Nursing-Quality Indicators
C489 task 1 Nursing Quality Indicators

Preview text
C489 Task 2
WGU Professor Kevil Sauls
Amanda Smith 12/19/

A. The general purpose of conducting a root cause analysis is a systematic approach to understanding the causes of an adverse event and identifying system flaws that can be corrected to prevent the error from happening again (Patient Safety 104,2021). Root cause analysis is not done to look for a person to blame but rather to look for what system flaws led to the incident. A1. An RCA is conducted using six steps by a team of typically four to six people from within the organization and with a mix of different professions with each of them having knowledge of the incident and the policies and procedures related to the incident. The first step is to identify what happened. In this step, it is important for the team to accurately determine what happened leading up to and during the incident. In the second step, the team will determine what should have happened during the incident. In the second step, the team will look at the incident and using their knowledge, skills, policies, and procedures will determine what the situation would have looked like and what the outcome would have been in an ideal perfect situation. In the third step, the team will determine the causes of the incident by asking why five times. In this step, the team looks at all the information and determines the contributing factors to the incident. A fishbone diagram is a graphic tool that is sometimes useful and used to display the possible causes of an event. There are seven different factors that should be examined in this step that can influence clinical practice and medical error: Patient characteristics, task factors, individual staff members, team factors, work environment, organizational and management factors, and institutional context (Patient Safety 104, 2021). In step four they will develop a causal statement that links the cause of the incident back to the effect and shows how that related to the incident. A causal statement has three parts the cause, the effect, and the event. In step five the team will generate a list of recommended actions or changes that should be done to prevent an incident like the one being evaluated from occurring again. There are nine categories that recommend changes usually fall under and those range from standardizing equipment to developing new policies. The recommendations can involve educating staff, instituting a backup/double-check system, using checklists, simplifying the steps in a procedure, the use of a force function, and changing the physical plant. In step six the final step the team writes up a summary of the event and all the data collected in steps one through five and share it with the key players involved.

A2. In the scenario with Mr. B when using the RCA process, I was able to identify many contributing factors that lead to the cause resulting in the death of Mr. B. One of the contributing factors in Mr. B’s scenario was insufficient staffing and not calling for backup when necessary. The day Mr. B went to the emergency room there was one RN, one LPN, one secretary, one physician, and one respiratory therapist working. Another causative factor is the amount of sedation medication given in such a small-time frame. Mr. B’s history of narcotic use for back pain is also a contributing factor regarding the amount of narcotics used and the physician and nurses’ decision to use those amounts. Other contributing factors were the nurse not administering oxygen during and after the procedure, the LPN resetting/silencing the alarm on the machine when alarming low and not reporting it to the RN, and the physician and the RN not following the conscious sedation policy that was currently in place. Many causative factors occurred with Mr. B that could have been avoided and would have resulted in Mr. B not passing away.

B. When developing a process improvement plan to decrease the likelihood of a reoccurrence of Mr. B’s sentinel event I would first develop a team with individuals from different departments such as someone from quality, risk management, emergency room doctor, RN, respiratory therapist, and legal. The next step would be for the team to access what happened in Mr. B’s sentinel event, determine the cause, develop a causal statement, and give their recommendations to the staff on how to proceed with this type of situation moving forward. Some key factors that contributed to the event were staffing, alarm fatigue, not following sedation policy, and administering too much medication in a short time frame. I would propose a sedation safety checklist to ensure the protocol is being followed and all steps have been performed but in a convenient user-friendly checklist. I would also create a staffing protocol that would be based on patient volume ad acuity which would require the charge nurse to call in the prn staff or standby staffing. In addition to a staffing protocol, I would suggest staggering the emergency room personnel’s shifts to ensure that there are always more than two nurses on at any given time. I would investigate initiating a force stop on the vital sign machine that would prevent personnel from being able to silence the machine so easily when alarming and would result in the individual having to acknowledge the cause of the alarm so that in cases like Mr. B’s the alarm can’t be silenced or turned off so easily when a patient’s oxygen levels are dangerously low. Staffing reeducation on the sedation policy and sedation medications would be an important part of the improvement plan as knowing the policy and the medications that are being used would prevent a future reoccurrence of Mr. B’s incident.

B1. Lewin’s change theory has three stages unfreezing, change, and refreezing. Lewin’s theory assists in changing processes or behaviors that are counterproductive. The first stage unfreezing involves making others aware that change is needed. In the scenario with Mr. B, the proposed improvement plan would start by notifying the staff of the sentinel event and the identified contributing factors that lead up to the event without placing blame on

education department should be appointed to review all employees who have been signed off for being reeducated on sedation protocol and sedation medications and set up a reeducation plan to ensure staff stays current on education. E. Nurses play a vital role in healthcare and demonstrate leadership in many different ways to ensure the best outcomes for their patients. Nurses promote quality care leadership by being an advocate for their patients, having good communication skills, collaborating with the interdisciplinary team, and staying educated on the policies and procedures in their department. Nurse leaders use evidence-based practice to improve patient outcomes. Nurses play a vital role in influencing quality improvement activities because they are the ones on the front lines implementing the interventions proposed by the quality department and know firsthand what is working and what isn’t working. Nurses can help the team to understand the different parts involved in the procedures and help to identify the possible failures that need to be changed to ensure better patient outcomes. The involvement of professional nurses in the RCA and FMEA process would be invaluable as nurses are the eyes and ears of the hospital and their knowledge and skills are a great asset to these teams and help to improve patient outcomes. Nurses demonstrate leadership every day and have taken on the leadership role in different departments within the hospital as they have a wealth of knowledge and skills that have been proven to be a great asset to the different departments within the hospital such as risk management, quality improvement, informatics, clinical documentation specialists, management, and many more.

References

1. Patient Safety 104: Root Cause and Systems Analysis Summary Sheet. (n.).
   Retrieved December 19, 2021, from
   ihi/education/ihiopenschool/Courses/Documents/SummaryD
   ocuments
2. Institute for Healthcare Improvement. (2019). Failure modes and effects
   analysis (FMEA) tool. Ihi.
   ihi/resources/Pages/Tools/FailureModesandEffectsAnalysisToo
   l
   Download
   Save
   anyone individual and reeducating them on the policies and procedures that were currently
   in place at the time of the sentinel event. In the second stage “change” the appointed team
   would talk to the staff about the new policies that are going to be implemented such as a
   sedation checklist, staffing protocols, a force stop on alarms, and reeducation plans for
   sedation protocols and sedation medications. In this phase, it is important to allow feedback
   from the employees on the new changes to get their perspective and review if any additional
   changes need to be made before stage three. In Lewin’s third stage refreezing the changes
   made in stage two are now implemented and become the new status quo. All new
   employees would be notified of the changes to how the sedation procedures will be
   performed, the new staffing protocols, and when and how it is to be used moving forward
   and notified of how and when mandatory education will be occurring. The team should
   appoint two members of the team to follow up periodically with the emergency room
   personnel to ensure the new changes are being used by all staff members all the time.
   C. The failure mode and effects analysis tool is a systematic, proactive method for
   evaluating a process to identify where and how it might fail and to assess the relative
   impact of different failures, to identify the parts of the process that are most in need of
   change (Institute for Healthcare Improvement, 2019). The FMEA tool is used as a
   proactive process to help avoid adverse events such as the scenario with Mr. B. There are
   three steps in the FMEA tool. The first step is a failure mode where you look at what
   could go wrong in the scenario. The second step is failure causes which looks at why
   would the failure happen. The third step is failure effects which evaluates what would be
   the consequences of the failure. By using this tool and working through the steps
   beforehand allows you to play out all the different possible outcomes and proactively
   help to prevent failure/harm.
   D. To ensure that another adverse outcome like the one with Mr. B doesn’t occur again
   when doing a conscious sedation procedure, the team would need to test the
   interventions that they came up with within the process improvement plan. I would
   appoint a member of the team such as an individual from the quality improvement
   department to perform random chart audits to determine if the sedation checklist is
   being used and all parts are being documented according to the new checklist. If there
   are areas on the sedation checklist that are still not being performed the team will need
   to reevaluate the cause and work towards creating a checklist that is appropriate for the
   procedure and staff and work with management to ensure the checklist is always being
   used. Regards staffing the director of the emergency room would be appointed to look
   back at trends from when the patient census was high and look at the acuity of those
   patients and compare that to the number of nurses on staff at the time. With the data
   collected the director would then look at the staffing protocols to determine if the new
   staffing protocol was followed and that there was an appropriate nurse to patient ratio.
   If it is determined that the protocol isn’t working then the team would need to
   reevaluate the staffing needs and how to improve the protocol. A member from the
   education department should be appointed to review all employees who have been
   signed off for being reeducated on sedation protocol and sedation medications and set
   up a reeducation plan to ensure staff stays current on education.
   E. Nurses play a vital role in healthcare and demonstrate leadership in many different
   ways to ensure the best outcomes for their patients. Nurses promote quality care
   leadership by being an advocate for their patients, having good communication skills,
   collaborating with the interdisciplinary team, and staying educated on the policies and
   procedures in their department. Nurse leaders use evidence-based practice to improve
   patient outcomes. Nurses play a vital role in influencing quality improvement activities
   because they are the ones on the front lines implementing the interventions proposed
   by the quality department and know firsthand what is working and what isn’t working.
   Nurses can help the team to understand the different parts involved in the procedures
   and help to identify the possible failures that need to be changed to ensure better
   patient outcomes. The involvement of professional nurses in the RCA and FMEA process
   would be invaluable as nurses are the eyes and ears of the hospital and their knowledge
   and skills are a great asset to these teams and help to improve patient outcomes. Nurses
   demonstrate leadership every day and have taken on the leadership role in different
   departments within the hospital as they have a wealth of knowledge and skills that have
   been proven to be a great asset to the different departments within the hospital such as
   risk management, quality improvement, informatics, clinical documentation specialists,
   management, and many more.
   References
3. Patient Safety 104: Root Cause and Systems Analysis Summary Sheet. (n.d.).
   Retrieved December 19, 2021, from
   http://www.ihi.org/education/ihiopenschool/Courses/Documents/SummaryD
   ocuments
4. Institute for Healthcare Improvement. (2019). Failure modes and effects
   analysis (FMEA) tool. Ihi.org.
   http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisToo
   l.aspx
   Recommended for you 7
   C489 Task 2 SAT TASK 2: Root Cause Analysis AND FMEA
   C489 Task 2 SAT TASK 2: Root Cause Analysis AND FMEA
   Organizational System100% (4)
   9
   C489 Organizational Systems and Quality Leadership
   C489 Organizational Systems and Quality Leadership
   Organizational System100% (3)
   13
   C489 task 2 organizational system
   C489 task 2 organizational system
   Organizational System100% (2)
   5
   C489 SAT1 TASK 1 passed no revisions!!
   C489 SAT1 TASK 1 passed no revisions!!
   Organizational System100% (2)
   5
   Organizational Systems and Quality Leadership Task 1
   Organizational Systems and Quality Leadership Task 1
   Organizational System100% (2)
   1
   C489 FMEA Table
   C489 FMEA Table
   Organizational System100% (2)
   16
   Task 2 Final – Task 2
   Task 2 Final – Task 2
   Organizational System100% (1)
   6