APPLICATION RCA & FMEA TO A HEALTHCARE SCENARIO
With the Nurse as a Member of the Healthcare Team
Competencies:
Principles of Leader ship – The graduate applies principles of leadership to promote
high-quality healthcare in a variety of settings through the application of sound leadership
principles.
Interdisciplinary Collabo ration – The graduate applies theoretical principles necessary for
effective participation in an interdisciplinary team.
Quality and Patien t Safety – The graduate applies quality improvement processes
intended to achieve optimal healthcare outcomes, contributing to and supporting a culture
of safety.
Healthcare Utilization an d Finance – The graduate analyzes financial implications related
to healthcare delivery, reimbursement, access, and national initiatives
Introduction:
Healthcare organizations accredited by the Joint Commission are required to conduct a root
cause analysis (RCA) in response to any sentinel event such as the one described below.
Once the cause is identified and a plan of action established, it is useful to conduct a failure
mode and effects analysis (FMEA) to reduce the likelihood that a process would fail. As a
member of the healthcare team in the hospital described in this scenario, you have been
selected as a member of the team investigating the incident.
Scenario:
It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient, arrives at the six-room
emergency department (ED) of a sixty-bed rural hospital. He has been brought to the
hospital by his son and neighbor. At this time, Mr. B is moaning and complaining of severe
pain to his (L) leg and hip area. He states he lost his balance and fell after tripping over his
dog.
Mr. B was admitted to the triage room where his vital signs were B/P 120/80, HR-88
(regular), T-98.6, R-32, and his weight was recorded at 175 pounds. Mr. B. states that he
has no known allergies and no previous falls. He states, “My hip area and leg hurt really
bad. I have never had anything like this before.” Patient rates pain at ten out of ten on the
numerical verbal pain scale. He appears to be in moderate distress. His (L) leg appears
shortened with swelling (edema in the calf), ecchymosis, and limited range of motion
(ROM). Mr. B’s leg is stabilized and then he is further evaluated and discharged from triage
to the emergency department (ED) patient room. He is admitted by Nurse J. The admitting
nurse finds that Mr. B has a history of impaired glucose tolerance and prostate cancer. At
Mr. B’s last visit with his primary care physician, laboratory data revealed elevated
cholesterol and lipids. Mr. B’s current medications are atorvastatin and oxycodone for
chronic back pain. After the nurse completes Mr. B’s assessment, Nurse J informs the ED
physician of admission findings and the ED physician proceeds to examine Mr. B.
Staffing on this day consists of two nurses (one RN and one LPN), one secretary, and one
emergency department physician. Respiratory therapy is in-house and available as needed.
At the time of Mr. B’s arrival, the ED staff is caring for two other patients. One patient is a
43-year-old female complaining of a throbbing headache. The patient rates current pain at
four out of ten on numerical verbal pain scale. The patient states that she has a history of
migraines. She received treatment, remains stable, and discharge is pending. The second
patient is an eight-year-old boy being evaluated for possible appendicitis. Laboratory results
are pending for this patient. Both of these patients were examined, evaluated, and cared for
by the ED physician and are awaiting further treatment or orders.
After evaluation of Mr. B, Dr. T, the ED physician, writes the order for Nurse J to administer
diazepam 5 mg IVP to Mr. B. The medication diazepam is administered IVP at 4:05 p.m.
After five minutes, the diazepam appears to have had no effect on Mr. B, and Dr. T instructs
Nurse J to administer hydromorphone 2 mg IVP. The medication (hydromorphone) is
administered IVP at 4:15 p.m. After five minutes, Dr. T is still not satisfied with the level of
sedation Mr. B has achieved and instructs Nurse J to administer another 2 mg of
hydromorphone IVP and an additional 5 mg of diazepam IVP. The physician’s goal is for the
patient to achieve skeletal muscle relaxation from the diazepam, which will aid in the
manual manipulation, relocation, and alignment of Mr. B’s hip. The hydromorphone IVP was
administered to achieve pain control and sedation. After reviewing the patient’s medical
history, Dr. T notes that the patient’s weight and current regular use of oxycodone appear
to be making it more difficult to sedate Mr. B.
Finally at 4:25, the patient appears to be sedated and the successful reduction of his (L) hip
takes place. The patient appears to have tolerated the procedure and remains sedated. He
is not currently on any supplemental oxygen. The procedure concludes at 4:30 p.m. and Mr.
B is resting without indications of discomfort and distress. At this time, the ED receives an
emergency dispatch call alerting the emergency department that the emergency rescue unit
paramedics are en route with a 75-year-old patient in acute respiratory distress. Nurse J
places Mr. B on an automatic blood pressure machine programmed to monitor his B/P every
five minutes and a pulse oximeter. At this time Nurse J leaves his room. The nurse allows
Mr. B’s son to sit with him as he is being monitored via the blood pressure monitor. At 4:35,
Mr. B’s B/P is 110/62 and his O2 sat is 92%. He remains without supplemental oxygen and
his ECG and respirations are not monitored.
Nurse J and the LPN on duty have received the emergency transport patient. They are also
in the process of discharging the other two patients. Meanwhile, the ED lobby has become
congested with new incoming patients. At this time, Mr. B’s O2 saturation alarm is heard
and shows “low O2 saturation” (currently showing a sat of 85%). The LPN enters Mr. B’s
room briefly and resets the alarm and repeats the B/P reading.
Nurse J is now fully engaged with the emergency care of the respiratory distress patient,
which includes assessments, evaluation, and the ordering respiratory treatments, CXR, labs,
etc.
At 4:43, Mr. B’s son comes out of the room and informs the nurse that the “monitor is
alarming.” When Nurse J enters the room, the blood pressure machine shows Mr. B’s B/P
reading is 58/30 and the O2 sat is 79%. The patient is not breathing and no palpable pulse
can be detected.
A STAT CODE is called and the son is escorted to the waiting room. The code team arrives
and begins resuscitative efforts. When connected to the cardiac monitor, Mr. B is found to
be in ventricular fibrillation. CPR begins immediately by the RN, and Mr. B is intubated. He
is defibrillated and reversal agents, IV fluids, and vasopressors are administered. After 30
minutes of interventions, the ECG returns to a normal sinus rhythm with a pulse and a B/P
of 110/70. The patient is not breathing on his own and is fully dependent on the ventilator.
The patient’s pupils are fixed and dilated. He has no spontaneous movements and does not
respond to noxious stimuli. Air transport is called and, upon the family’s wishes, the patient
is transferred to a tertiary facility for advanced care.
Seven days later, the receiving hospital informed the rural hospital that EEG’s had
determined brain death in Mr. B. The family had requested life-support be removed, and Mr.
B subsequently died.
Additional information: The hospital where Mr. B. was originally seen and treated had a
moderate sedation/analgesia (“conscious sedation”) policy that requires that the patient
remains on continuous B/P, ECG, and pulse oximeter throughout the procedure and until the
patient meets specific discharge criteria (i.e., fully awake, VSS, no N/V, and able to void).
All practitioners who perform moderate sedation must first successfully complete the
hospital’s moderate sedation training module. The training module includes drug selection
as well as acceptable dose ranges. Additional (backup) staff was available on the day of the
incident. Nurse J had completed the moderate sedation module. Nurse J had current ACLS
certification and was an experienced critical care nurse. Nurse J’s prior annual clinical
evaluations by the manager demonstrated that the nurse was “meeting requirements.”
Nurse J did not have a history of negligent patient care. Sufficient equipment was available
and in working order in the ED on this day.
Task:
A. Complete an appropriate root cause analysis (RCA), with substantial detail, that takes
into consideration causative factors, errors, and/or hazards that led to the sentinel event
(this patient’s outcome).
B. Discuss a logical process improvement plan, with substantial detail, that would decrease
the likelihood of a reoccurrence of the outcome of the scenario.
1. Discuss a logical change theory, with substantial detail, that could be used to implement
the process improvement plan developed in B.
C. Use a failure mode and effects analysis (FMEA), with substantial support, to project the
likelihood that the process improvement plan you suggest would not fail.
1. Accurately identify the members of the interdisciplinary team who will be included in the
FMEA.
2. Logically discuss steps, with substantial detail, for preparing for the FMEA.
3. Appropriately apply the three steps, with substantial detail, of the FMEA ( severity,
occurrence, and detection ) to the process improvement plan created in part B.
4. Logically explain, with substantial support, how you would test the interventions from
the process improvement plan from part B to improve care in a similar situation.
Note:You are not expected to carry out the full FMEA, but you should explain each step,
and how you would apply it to your process improvement plan.
D. Logically discuss, with substantial detail, how the professional nurse may function as a
leader in promoting quality care and influencing quality improvement activities.
E. When you use sources to support ideas and elements in this paper, please provide
acknowledgement of source information for any content that is quoted, paraphrased or
summarized. Acknowledgement of source information includes in-text citation noting
specifically where in the submission the source is used and a corresponding reference,
which includes:
• Author
• Date
• Title
• Location of information (e.g., publisher, journal, or website URL)

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