Conducting an RCA: Understanding Challenges & Taking Action - Research Paper

Introduction

According to Okes (2019), the RCA is a technique to respond to challenges that transpire. Thus, the general purpose of RCA is to analyze or problems to identify what occurred, how it transpired, why it happened, and the development of actions to prevent their occurrence.

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Steps Used to Conduct an RCA

In the RCA method, the first step is for the team to attempt to designate what transpired wholly and precisely, and they can achieve success by making a flowchart to create a picture of what occurred in the order it happened. Secondly, there is a need to define what could have happened in a suitable condition. On this information, it can be useful to create a chart that can then be compared with that of step one (Okes, 2019). In the third phase, the group defines the aspects that lead to the incident; they can achieve this by "asking why five times" to get at a root or underlying cause. The fourth step entails creating a causal statement comprising the event, the effect, and the reason. In the fifth step, the team recommends actions that they perceive would prevent the reoccurrence of the error under review. Lastly, the team makes a summary and share it to drive the next improvement steps.

Causative and Contributing Elements to the Scenario

Utilizing the RCA process to Mr. B's scenario would help to designate the contributing and causative dynamics that caused the sentinel incident aftermath. In this regard, Mr. B was heavily sedated with hydromorphone and diazepam, considering that he was under an oxycodone prescription, which is an opioid. The mixture of the two medications was bound to generate severe side effects, including difficulty in breathing as well as brain death, which transpired later. It was highly probable that the administered sedative would lead to undesired results given Mr. B's age and fragility of his health.

Process Improvement Plan

The proposed method development strategy that would lessen the chance of a reoccurrence of the incident consequence is the Lewis change theory. Lewis change model is influential for this case since it entails unfreezing the old behavior, implementing a new stage of practice, and refreezing the action at the latest stage (Cummings, Bridgman, & Brown, 2016). The reason for this is that in dynamic institutions, including hospitals, adjustments, and reorganizations often take place. Unfortunately, change usually encounter resistance because workers are not always happy with the transformation.

Application of Lewin's Change Theory to the Proposed Improvement Plan

Lewin's theory is comprised of three stages. The first one is the "unfreeze" phase. Based on the current scenario, the MD, RN, and LPN are only responding to each situation without a procedure or framework. The unfreeze stage will help in starting the process, where the MD, LPN, and RN will be receptive and open to a change in procedure and policy. The second stage is "change." With the current scenario, this phase will help the MD, LPN, and RN to understand why a change needs to transpire and the accountability for care that should be followed. The last phase is "refreeze," which is vital since it cements effectiveness. Once the MD, LPN, and RN have a more transparent and precise policy to follow and are invested in the change, the satisfaction of patients will excel, which, as a result, will increase the morale of the staff.

Purpose of the Failure Mode and Effects Analysis (FMEA) Process

FMEA is a preemptive and systematic technique for assessing a practice to find out how and where it might fail. The method also evaluates the comparative effects of diverse failures in categorizing the segments of the development that are most in need of amendment.

Stages of the FMEA Method

The FMEA technique comprises seven phases. The first one entails analyzing a new process that needs to be adopted. Step two requires enlisting a multidisciplinary team made up of individuals who are directly involved in the process to be evaluated (Cristian & Batmangelich, 2015). Thirdly, the organization defines the process, to ensure the team members understand. Fourthly, the team evaluates what could go wrong in the course of each step of the method. The fifth step is to make a shortlist of problems that can be fixed, and which could recur during the process. Step six is to implement and design the changes. The last step is to measure the success of the change process.

FMEA Table

Testing the Interventions

The primary method to evaluate the intervention proposed in step B would be through the assessment of how the monitoring is conducted. The proposed solution will be successful if the level of monitoring the patient is done within short timelines and at a high rate without failure. Nonetheless, if the process is not conducted efficiently, it implies that the intervention plan was not implemented successfully. Conversely, feedback from the patients would also be essential in determining if the program was successful (London, 2015). Negative reviews and feedback will show that it was not successful; conversely, positive feedback and discussions will indicate that it was successful.

Key Roles of Nurses

A specialized nurse can thoroughly demonstrate guidance in supporting quality care by ensuring to align their services with the resources available to meet the patients' needs and prioritize the care of patients. Furthermore, they can improve patient outcomes by working in collaboration with other professionals in a healthcare organization to ensure the needs of the patients are met (Houser, 2016). Last but not least, nurses can influence quality improvement activities through user feedback, nurse and physician champions, individual accountability, a philosophy of quality as the responsibility of everyone, and supportive leadership.

Professional Nurses in the RCA and FMEA Processes

The participation of nurses in RCA and FMEA indicate that they have leadership qualities and can assist health institutions in identifying problems, intervention plans, and solutions through teamwork and critical thinking.

References

Cummings, S., Bridgman, T., & Brown, K. G. (2016). Unfreezing change as three steps: Rethinking Kurt Lewin's legacy for change management. Human relations, 69(1), 33-60.

Cristian, A., & Batmangelich, S. (2015). Physical medicine and rehabilitation: patient-centered care: mastering the competencies. Demos Medical.

Houser, J. (2016). Nursing research: Reading, using and creating evidence. Sudbury: Jones & Bartlett Learning.

London, M. (2015). The power of feedback giving, seeking, and using feedback for performance improvement. New York, NY: Routledge.

Okes, D. (2019). Root cause analysis: the core of problem solving and corrective action. Milwaukee, WI: ASQ Quality Press.