The main objective of this study is to understand, evaluate and analyze the fateful sentinel event, which struck Mr. B, who was sixty- seven years old and was taken to the Emergency Department (ED) of a sixty bed rural hospital. Mr. B complained to Nurse J of rigorous pain in his hip and left leg after he lost his balance and fell after tripping over his dog. The ED physician and nurse after thorough medical check up treated Mr. B. However, within thirteen minutes of the treatment procedure, Mr. B's health started deteriorating. He was kept on ventilator and was then transferred to a tertiary facility for advanced care where after seven days; the physicians concluded that Mr. B had attained brain death. Due to sudden death of Mr. B, a root cause analysis (RCA) is needed in order to investigate the causative factors, errors and/ or hazards that lead to such an event. In order to do so, I will utilize change theory that will help in developing an appropriate improvement strategy to decrease the probability of repetition of consequence, which the hospital faced in case of Mr. B. Following this, Failure Modes and Effects Analysis (FMEA) will be done in order to ensure that the suggested improvement plan would not fail in future. Lastly, the function of the professional nurses as a leader in promoting the quality care in scenarios such as Mr. B's will be discussed.
A. Root Cause Analysis - Causative Factors
A root cause analysis (RCA) provides an evidence- based structure used to identify the basic or casual factors, which triggers the variation in performance, including the occurrence or the probability of occurrence of a sentinel event . In Mr. B's case, the attendants at the emergency room will be the ED physician (Dr. T), LPN and RN (Nurse T), the emergency room nurse manager and the chief nursing officer (CNO) of the hospital. All these participants will be involved during the root cause analysis to discuss the causative factors errors and/ or hazards that caused Mr. B's sentinel event. The primary step of this process would be to gather all the available data related to the incident from each of them. These data would incorporate details about his blood pressure (BP), medical history, biochemical parameters values, pain scores and the medication history dispensed during the event. The next step in this process will be to debrief the facts of Mr. B's sentinel event. Following this, the third step would be to question each of the causative factors, which led to Mr. B's death. In the next step of RCA, will including drilling down the data to identify other cause to his death. The biggest mistake done during this event was that Dr. T overestimated Mr. B's endurance power to the administered opiates. Dr. T did not consider Mr. Bs clinical situation i.e., his age and his renal function. He did not have enough knowledge on opiates he prescribed. Therefore, analyzing the whole data, it was learnt that the major causative factor and the event leading to Mr. B's sentinel event was wrong decision and the medication error done by Dr. T. During the treatment, Mr. B was administered with over- dose of Hydromorphone, which his system could not bear and resulted in brain death within thirteen minutes after the end of treatment. The final step of the root cause analysis process is to strategizing interventions and implementing it in order to mitigate the root cause of the crisis. In Mr. B's fateful event, what I learnt was that both Nurse J as well as Dr. T had little or no knowledge about the opiate that they administered in Mr. B. Dr. T ordered Nurse J to sedate Mr. B with diazepam 5 mg IVP. After five minutes when he saw Mr. B showed no improvement, Dr. T instructed Nurse J to administer 2mg IVP of Hydromorphone, which also had no effect on Mr. B. Since, Dr. T was not satisfied with the result he further instructed to inject 2mg of Hydromorphone with additional 5 mg of diazepam IVP, which had finally relaxed Mr. B's skeletal muscle. The whole incident happened in a span of 25 minutes. Dr. T's and Nurse J's treatment procedure that they applied on Mr. B proves that they lack adequate knowledge on sedating or anesthetizing their patient. Therefore, the foremost change that needs to be implemented in cases such as Mr. B's should include educating the ED physicians and the nursing staff about different opiates such as Hydromorphone, diazepam, etc. along with their side effects and their adverse effects. Training program needs to be conducted for ED staff in order to train and educate them on how to manage critical situations and deliver quality care to their patients.
Errors or Hazards. After properly scrutinizing Mr. B's case, it was learnt that there were many errors and hazards in the care delivery, which lead to Mr. B's sentinel event. One of the errors was the failure of the emergency rooms physician, Dr. T, to recognize the signs and symptoms of Deep Vein Thrombosis (DVT) that Mr. B was projecting. When conditions such as DVT are left unattended for a longer period of time, it can result in pulmonary embolism. Pulmonary embolism is a medical condition where the main arteries or one of the branches of the pulmonary arteries in the lungs is blocked by a substance that travels from elsewhere in the body through the bloodstream. This is what happened in Mr. B's case, where the DVT turned into a pulmonary embolism due to delay in treatments, which lead to Mr. B's death. The second error that happened in Mr. B's case was the failure of the nurse in monitoring Mr. B's ECG and respiration rates. Had Nurse J monitored the critical changes in Mr. B's ECG and respiratory rate earlier then they could have prevented Mr. B's death. One of the major hazards that occurred during this case was the heavy load of patients at the time of Mr. B's case in the Emergency Department. The second hazard was having the Licensed practical nurse (LPN) who acts as liability to the nurse in the fact aced, highly critical emergency room environment. The most important error was overdosing Mr. B with Hydromorphone. A total of 4 mg of Hydromorphone and 10 mg of diazepam within 20 minutes. Hydromorphone is a highly potent sedative which when administered in patients should be carefully monitored for severe respiratory depression.
B. Improvement Plan
An improvement plan, stemming from the change theory is essentially needed in order to reduce the probability of repetition of the events that took place in Mr. B's case. Thus, the change theory that I will be using in Mr. B's case would be Kurt Lewin model. The model works in three steps:
1.) Unfreeze - Make a radical change
2.) Transition - Minimize the disruption of the structure's operations
3.) Freeze - Make sure that the change is adopted permanently
This change theory guides in how to bring a change in the system in order to implement new processes by reinforcing new tasks and ensuring that the newly implemented task works effectively and will be suitable to use during practice. Thus, in this section, my aim will be to quickly test whether my plan would work or not. For which I will be first to unfreeze doctors of ED like Dr. T by changing their path of action i.e., their current practices will be reassessed in order to bring the change and set it in motion. Following this the new methodology will be implemented in the doctors and the nursing staff and they will be trained and tested to bring out efficiency so that the risks of reoccurrence diminishes. The transition plan will screen the Deep Vein Thrombosis patients in the emergency room. The procedures involved in this will include D- Dimer blood test, which is a diagnostic test to determine the probability of the patients who have DVT. The second intervention will be to prepare a flow chart that would detail the signs and symptoms of DVT. This will enable the physicians and the nursing staff in the ED to first screen their patients for DVT if they complain of extremity pains. Thus, if these changes are apt as improvements then the probability of reoccurrence of another Mr. B fatal event will reduce. The unfreezing step will then be used to test and tweak the new strategy for DVT screening procedure so that the newly implemented strategy is practice permanently with no errors. This step will make sure that health care team will take an advantage of the new strategy and implement it when needed, which in return will help in preventing fateful scenario's like Mr. B in future.
C1. Failure Models and Effects Analysis (FMEA)
The Failure Modes and Effects Analysis (FMEA) is a systematic and proactive process for evaluating a process that helps in identifying where and how the process might fail and assessing the relative impact of different failures in order to identify the parts of process, which needs to be changed . The main objective of using FMEA is to increase the probability that the process improvement plan that was improvised will not fail. The initial step of FMEA is to scrutinize the process by identifying the process flow. In this case, the FMEA will be used to analyze the new Hydromorphone monitoring process. The second step of FMEA in such scenarios will be to evaluate every single step in the new Hydromorphone monitoring process in order to check what could go wrong. These steps are known as the "failure modes" . In this event, the failure mode was the administration of wrong dose of Hydromorphone and inaccurate monitoring of cardiac and pulse oxygenation, while administering the opiate in Mr. B. A ranking scale is used for each failure mode in order to determine: 1) possibility that distress/ harm will happen if the case gets serious (Severity), 2) the possibility of the mishaps that will occur (Occurrence), and 3) lastly the possibility of detecting the cause that lead to the event (Detection). The last step of the FMEA process is to identify interventions that would improve the quality care, ensure patient's safety and reduce the probability of reoccurrence of similar events in future.
C2. Steps for preparing FMEA
The preparation of FMEA includes pre- steps. At first, a process needs to be selected which is simple in nature such as medicine management which is a smaller subset of a complex process. In this case, the process of Hydromorphone will be monitored. In the second step, a multi- disciplinary team will be assembled in order to outline the new Hydromorphone monitoring process. Anything that would fail while testing the new process and its corresponding causes could be listed down by the multidisciplinary team.
C3. Applying the three Steps of FMEA
The Failure Modes and Effects Analysis (FMEA) occurs in three steps: 1) Severity 2) Occurrence and 3) Detection. Severity is defined as the likelihood that if anything goes wrong, harm will occur i.e., how likely is the failure to occur if overdose of Hydromorphone and improper cardiac and pulse oxygenation monitoring in the patient occurs? Occurrence is the probability that what went wrong would occur i.e., How likely would the overdose of Hydromorphone dosage and the improper cardiac and oxygenation monitoring in patients would occur? Detection is the probability of what went wrong will be detected i.e., how likely will the failures be detected if there is overdose of Hydromorphone and the cardiac and pulse oxygenation monitoring done is wrong. The final step of the FMEA will be evaluating all the above- mentioned three tests.
It is important to bring changes in the care process, thus, new interventions will help in improving strategies for treating patients in similar situation as Mr. B. Establishing a clinical pharmacy program that specifically focuses on Hydromorphone administration will be the first intervention. Following it, the next intervention will be to initiate a standard pain assessment and reassessment protocol. The medical and the nursing staff of the emergency department will have to attend training where they will be educated on how to manage pain in cases similar to Mr. B where despite of opiate administration, the pain score never falls below five. A standard Hydromorphone order set with monitoring guidelines would be created for such cases where doctor's like Dr. T could use in the ED. These interventions will be tested for three months in the emergency room. During the trial period, all the medical records of the patient's that were administered with Hydromorphone in the emergency room will be checked. It is expected that these intervention that are listed above will prevent any of the reoccurrences of cases such as Mr. B.
D. Key role of professional Nurses
Improving the quality care delivery in cases such as Mr. B will be one of the major tasks of the professional nurses. Every LPN will have a huge impact in his/ her nursing practice by the Provision II of the American Nurses Association Code of Ethics. According to this provision, every nurse promotes, advocates for, and strived to protect the health, safety and rights of her patients . In order to prevent the reoccurrence of sentinel events such as Mr. B, the emergency room nurses should be more cautious while identifying the early signs and symptoms of critical illness that could result in sentinel events. The Emergency room nurses should keep monitoring the ECG and the respiratory changes of each patient from time to time. This would potentially reduce the risks of any sentinel events to occur.
In conclusion, the causative factors, errors or hazards that lead to the unfortunate death of Mr. B was investigated and evaluated by me with the help of Root Cause Analysis (RCA). For creating an improvement plan in order to reduce the likelihood of reoccurrence of fatal events such as in Mr. B's case, a Failure Modes and Effects Analysis (FMEA) was conducted and each step was thoroughly investigated. If proper planning would be followed then the nurses will play a major role in improving and preventing such cases to reoccur in future.
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