Essay Example on Root Cause Analysis and Failure Modes Analysis

Introduction

The concept of root cause analysis is ideal in the emergency department because it unveils the most likely cause of a failure when patients with critical conditions are handled. The root cause analysis is a comprehensive process that allows members of given organizations, more so the hospital emergency department section to understand the root cause of the problem and use it to solve problems. Six steps of root cause analysis are used to analyze an event regarding matters of patient safety unveils minute details that are essential when it comes to learning, events that are ideal for corrective measure. The second part, which is future mode and effect analysis, is a crucial tool because the two are incorporated to come up with the solution for the future worst-case scenario revolving around the issue with patient care. Failure modes, causes, and effects present a series of the future mode effect and analysis that are crucial and used to track the improvement of a process, patient care. The essay here analyses a sentinel event regarding patient care by incorporating six steps of route cause analysis and future modes effects and analysis.

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The General Purpose of Root Cause Analysis

The general purpose of the root cause analysis is used to identify the root causes of problem regarding the sentinel event of the patient Mr. B in an emergency department. The cause of the problem was severe pain of the left hip and the possible diagnostics as well procedure incorporated to manage his condition (medication). The analysis was also ideal in unveiling the emerged complication of the patient, which was brain death. The general purpose of the root cause was also about understanding of the event relating to patient healthcare. Finding and mapping the facts as well as determining the cause and effective action presents the ideal purpose of the root cause analysis of the event.

Six Steps Used to Conduct Root Cause Analysis

Identify what happened. It is one of the six steps of the root cause analysis, trying to draw a plan by describing the event to determine what happened. In this step, a flow chart was used to determine the event in a sequence manner. The problem was defined related to patient care in the sentinel event, and data was collected verifying the root cause of the problem.

Determine what should have happened is the second step. In the context of the second step, the team determined what primary healthcare should have done to manage the condition of Mr. B effectively (Abdelaziz et al. 2018). The medical professionals should have seek medical information from the patient prior to treatment procedure regarding the condition of Mr. B. Determining the cause was the third step incorporated in the root cause analysis to this event, sentinel event of Mr. B. Here the team looked at the most contributing factor that led to brain damage of patient during patient care. In the context of this scenario, the team identify the most likely causes of the brain damage, which was the drug used in moderating the patient condition, left hip pain. The drug was diazepam, and usually, it passes the brain barrier and associated with respiratory depression hence varying data and low oxygen concentration of the patient.

Develop causal sentiments and generate a list of recommended actions to prevent the event from occurring as well as information of a summary covers the fourth, fifth, and six steps of root cause analysis, respectively. In the case of recommendations, the team used forcing functions that physically prevent users from making common mistakes in that case of patient care, and this focused on the dose used by the doctor.

Process Improvement Plan

Developing new policies regarding patient care and using cognitive aids present list of the process improvement plan. The presented policies would enable proper handling of patients as well as the correct ratio of medical practitioners to patients to prevent such a scenario from reoccurring within the healthcare system. Each phase of change Lewin's theory is applicable in this scenario. Unfreezing, changing, and refreezing. The unfreezing phase would create awareness and incorporate the right number of nurses and doctors to attend to patient rightfully and at the expected time (Myer et al. 2018). It would also bring awareness to medical practitioners of essential dose to use to manage a condition without emerging complicating issues. Change is applicable in this scenario when it comes to implementation. The change in the number of a medical practitioner in this healthcare system is marked with realities and how procedures regarding patient care are initiated in the region.

The third phase, which is freezing, can be applied because it is the new state of organizational change (Dufour et al. 2019). Here organizational goals related to patient care as well as structure presents new norms to the organization. Medical practitioners such as nurses and doctors as well as physician get to accept the change. Policies in place would ensure the transition is maintained and never lost, thus cement to a related healthcare facility.

The General Purpose of Failure (FMEA)

Failure modes, failure causes, and failure effects present a series of failure modes effect and analysis tool that aid in unveiling the general purpose of failure. Failure mode focuses on the malfunctioning of the product used which in this case was the drug used by the doctor in managing condition of Mr. B. The first phase checks over what could go wrong in the case of drug used, diazepam 5mg. The second phase unveils the general cause. It employs the idea of why would the failure happen. In this case, the failure occurred because of the immense amount of drugs used in the case of trying to manage the patient condition using the drug. The failure happens because the drug is immensely associated with respiratory depression, and it is evident in the case of heart rate noted. Failure effects are the third phase that coves the general purpose of failure and is associated with the consequences of each failure. Death of the brain cell and lost life are the consequences of this failure effects covering the general purpose of the failure and effects analysis.

Scale of Severity

Severity scale in this section covers the intensity of pain Mr. B experience as recorded in scale. The occurrence of pain was on the left hip of the patient. On the scale, the B/P was 120/80, suggesting elevated blood pressure and on the other hand, HR-88 showing standard heart rate. After the medical care and evaluation, readings were recorded to 58/30, suggesting with 85% oxygen saturation.

Intervention

I would test the intervention through planning a test, and this can be achieved through observation as one of the method as well as collecting data. Medical data from this section would contribute to improving health care services within healthcare systems. The second way I would test the invention is by carrying out a small test. Effectiveness of the intervention can be achieved from the small test regarding its efficacy in healthcare facilities. Setting aside time to analyze data would also be an essential way to test interventions, thus improving quality of care in the improvement plan.

Professional Nurse

The professional nurse can demonstrate leadership in promoting quality care by effectively collaborating with patients, families, as well as health care settings in any healthcare system. Professional nurses can also improve on the quality of care by executing essential medical practices safety to become competent, thus leadership qualities. Nurses can improve the patients' outcome and demonstrate leadership by initiating well-informed diagnostics relating to medical conditions (Taliaferro et al. 2019). He or she can also demonstrate leadership by promoting optimal treatment plans of patients with complicating medical conditions. They can influence quality improvement within the healthcare system by taking part in quality improvement activities within the healthcare organization.

Nurses Leadership Qualities (RCA and FMEA)

Professional nurses can demonstrate leadership qualities in the root cause analysis processes as well as in failure mode and effects analysis by providing a suggestive recommendation that is relevant to sentinel event more so in the case of Mr. B. A professional nurse can promote quality care as one way of demonstrating leadership quality in root cause analysis. By leading the group, the professional nurse would set an essential section of leadership.

Conclusion

To sum up, the six steps of root cause analysis are essential in the sentinel evident because each one unveils the sequence of evident that happened. Failure mode and effect analysis were used to determine the general purpose of failure during the medical condition of Mr. B. A professional nurse can demonstrate leadership qualities by taking part in the steps of root cause analysis.

References

Abdelaziz, A., Elhoseny, M., Salama, A. S., & Riad, A. M. (2018). A machine learning model for improving healthcare services in a cloud computing environment. Measurement, 119, 117-128.

Dufour, I., Lacasse, A., Chouinard, M. C., Chiu, Y., & Lafontaine, S. (2019). Health literacy and the use of healthcare services among community-dwelling older adults living with chronic conditions. Clinical Nursing Studies, 7(2), 79-86.

Myer, L., Phillips, T. K., Zerbe, A., Brittain, K., Lesosky, M., Hsiao, N. Y., ... & Abrams, E. J. (2018). Integration of postpartum healthcare services for HIV-infected women and their infants in South Africa: A randomized controlled trial. PLoS medicine, 15(3), e1002547.

Taliaferro, L. A., Harder, B. M., Lampe, N. M., Carter, S. K., Rider, G. N., & Eisenberg, M. E. (2019). Social Connectedness Factors that Facilitate the Use of Healthcare Services: Comparison of Transgender and Gender Nonconforming and Cisgender Adolescents. The Journal of pediatrics.