Rca and Fmea Essay

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Root Cause Analysis:

Root cause analysis (RCA) is used in different fields to conduct a systematic search to find the causes of a specific sentinel event (Jacob, 2010). The main goal for conducting a RCA is to prevent similar adverse events from happening in the future (Jacob, 2010). In this paper, I will use the scenario provided in the task to create a complete RCA report as well as improvement plans that will prevent similar incidents from happening again. RCA is best done as soon as an adverse event has happened (Jacob, 2010). The first step in the RCA is to identify what had happened (Jacob, 2010). In the scenario, Mr. B was admitted to the Emergency Room (ER) after a fall. During the treatment, Mr. B was given …show more content…
All the above causative factors have lead to the sentinel event which was Mr. B’s death. Errors from the scenario included, Mr. B was not monitored during the moderate sedation and his ECG was not monitored during the recovery from the sedation. The LPN who went in to turn off the alarm the first time also did not inform either Nurse J or Dr. T that Mr. B’s oxygen saturation was low. Additional staffs were available but no one was called to help on the floor when additional patients were admitted from the emergency dispatch. A. Process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario:

The main error from the scenario was that Mr. B was not on continuous blood pressure, ECG, and pulse oximeter monitoring throughout the moderate sedation process. The hospital does have a policy which requires anyone who is going through moderate sedation to be monitored until they meet certain discharge requirement; the policy was just not implemented at the time when Mr. B was admitted. The process improvement plan that I am proposing is to have all the staffs in the ER department to review the moderate sedation policy weekly. Nurses and doctors might be distracted by the patient load and forgets some details from the policy, but if everyone is aware of the policy, it increases the chances that other

New Conscious Sedation Checklist

required to attend additional training on the new conscious sedation checklist. A laminated conscious sedation checklist and conscious sedation checklist forms will be readily available in all areas where conscious sedation takes place. B1. Change Theory The staff members will need to buy into the new conscious sedation checklist. Lewin Change Theory consists of three stages: unfreezing, freezing, and refreezing. The first stage in helping people adapt to change involves unfreezing their attachment…

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Health Care and Emergency Transport Patient Essay

assess that monitor alarms are functioning appropriate. FMEA is a great tool to be used in risk analysis and quality control, its use proactively evaluates health care processes. The FMEA steps are: Step One: Select a process to evaluate with FMEA. Step Two: Recruit the Multidisciplinary team. Team is anyone who comes in contact with patient. Step Three: Team to meet to discuss the steps in the process. Presteps for preparing for the FMEA are evaluating subgroups, identify a potential issue and…

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Examples Of Root Cause Analysis

unnecessary death of a patient. A root cause analysis (RCA) can be utilized to help understand the systems at fault within the facility so that improvements can be determined and implemented to prevent any future occurrences (Cherry, 456). RCAs focus on systems rather than blaming individuals involved, therefore they are only appropriate in cases where there has been no willful negligence or criminal acts (Huber & Ogrinc, 2014). The overall purpose of RCAs is to find out the causes of the adverse event and…

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RTT1 Task 2 Essay

Governors University Leslie Baylor A. Complete a root cause analysis (RCA) that takes into consideration causative factors that led to the sentinel event (this patient’s outcome). “A central tenet of Root Cause Analysis (RCA) is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals” (AHRQ, 2012). The prevention of errors is the main emphasis of a RCA. The process begins with gathering data in regards to the event, then…

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C489 Task 2 Essay

The Unfortunate Hospital Experience for Mr. B Identification of Events * Mr. B presents to the Emergency Room with complaints of Left hip and leg pain * His son is at the bedside * Dr. T assesses Mr. B determining that he needs to set Mr. B’s hip at the bedside. * Dr. T orders moderate sedation * Mr. B takes oxycodone for chronic pain * Nurse J is assigned to care for Mr. B * Nurse J administers medications per Dr.T’s orders * 5 mg of Diazepam…

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Qcf Level 3 Unit 1

B1. Reflect on your professional definition of quality and safety developed in Professional Roles and Values, including any necessary changes to your definition. Before I enrolled in the Professional Roles and Values class at Western Governors University, my definition of “Quality and Safety” merely meant, practice safe nursing, which I interpreted as following the guidelines, rules, and regulations of the state you are licensed in and the facility you work for. After taking the Professional…

Words 671 - Pages 3