WGU C489 SAT TASK 2 RCA and FMEA Paper
A. Root Cause Analysis (RCA):
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Write My Essay For Me!- Six Steps of RCA:
a. Define the problem: Clearly outline the issue or event that occurred. In this scenario, it’s the unexpected death of Mr. B after undergoing a procedure in the emergency department.
b. Collect data: Gather relevant information related to the event, including patient history, actions taken, and environmental factors.
c. Identify possible causal factors: Determine the root causes and contributing factors that led to the event. This may include human errors, system failures, or communication breakdowns.
d. Identify root causes: Dig deeper to find the underlying reasons behind the identified causal factors. This involves asking “why” multiple times to get to the fundamental cause.
e. Recommend and implement solutions: Develop corrective actions to address the root causes and prevent similar events from happening in the future.
f. Monitor and evaluate: Continuously assess the effectiveness of implemented solutions and make adjustments as needed. - Application to Scenario:
a. Causative Factors:- Failure to adequately sedate the patient due to factors such as weight, medication history, and resistance to sedatives.
- Lack of continuous monitoring as per hospital policy during and after the procedure.
- Overburdened staff and congested ED leading to divided attention and delayed response to critical alarms.
b. Contributing Factors: - Inadequate communication between staff regarding patient condition and monitoring requirements.
- Lack of sufficient backup staff to handle emergencies and patient load.
- Failure to recognize deteriorating patient condition promptly.
B. Process Improvement Plan:
- Lewin’s Change Theory:
a. Unfreezing: Engage staff in understanding the need for change and the severity of the incident. Provide education on sedation protocols and the importance of continuous monitoring.
b. Moving: Implement changes such as mandatory continuous monitoring during and after procedures, enhanced communication protocols, and adequate staffing levels.
c. Refreezing: Reinforce the new protocols through regular training, audits, and feedback mechanisms. Ensure compliance through accountability measures.
C. Failure Mode and Effects Analysis (FMEA):
- Purpose of FMEA:
- Identify potential failure modes in a process, assess their impact, and prioritize actions to mitigate risks.
- Steps of FMEA:
a. Identify processes: Define the process being analyzed, in this case, sedation and monitoring during procedures.
b. Identify failure modes: Determine potential failure modes such as inadequate sedation, lack of monitoring, or delayed response to alarms.
c. Assess severity, occurrence, and detection: Rate the severity of each failure mode, its likelihood of occurring, and the likelihood of detection before harm occurs.
d. Calculate risk priority number (RPN): Multiply severity, occurrence, and detection scores to prioritize actions.
D. Testing Interventions:
- Implement the proposed changes in a controlled setting, monitor their impact on patient outcomes, staff compliance, and system efficiency. Collect data on sedation effectiveness, monitoring adherence, and response time to alarms. Adjust interventions as necessary based on observed results.
E. Nursing Leadership:
- Promoting Quality Care: Nurses lead by ensuring adherence to best practices, advocating for patient safety protocols, and participating in quality improvement initiatives.
- Improving Patient Outcomes: Nurses drive efforts to enhance patient outcomes through evidence-based practice, patient education, and interdisciplinary collaboration.
- Influencing Quality Improvement Activities: Nurses play a pivotal role in identifying areas for improvement, implementing changes, and evaluating their impact on patient care and safety.
Involvement in RCA and FMEA:
- Nurses demonstrate leadership by actively participating in RCA and FMEA processes, contributing insights from frontline experience, and advocating for patient-centered solutions. They facilitate communication between multidisciplinary teams, promote a culture of safety, and drive continuous improvement efforts to prevent adverse events and enhance overall care delivery.
WGU C489 SAT TASK 2 RCA and FMEA Paper
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