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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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HCR 220 Week 8 DQ 2
Why is it important to prepare a clean claim? What suggestions might you make to ensure that submission of a clean claim takes place? Provide examples.
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In the chapter, “How Community-Based Organizations Are Addressing Nursing’s Role in Transforming Health Care,” the authors describe the community as the focus of advocacy action for change. They list a series of questions that help community teams develop organizing principles to guide their interventions, and the aim is to attack social determinants of health to make community change.
Suppose a community team identifies lack of access to exercise modalities as a public health issue. If the team were to determine that pedestrian walkways need to be constructed, discuss at least two factors that would facilitate the development of the walkways and two that would hinder the development. For the hindrances, discuss ways that the team might work to overcome those hindrances.
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">Interdisciplinary Perspectives in Healthcare
The Community Health Center has emerged as an increasingly important setting and focus for a collaborative, interdisciplinary approach to delivering health care. Political and economic realities promise to magnify the role of this institution.
To prepare:
For this Discussion, review this week’s Required Resources and reflect on the ramifications and potential for collaboration in community health centers.
Post a comprehensive response to the following:
- Identify what you believe are the two key benefits of collaboration for community health centers.
- How do you feel health care reform will promote or hinder collaboration and an interdisciplinary approach at community health centers?
Support your arguments with specific citations from this week’s readings.
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RESOURCES
Dieleman, S., Farris, K., Feeny, D., Johnson, J., Tsuyuki, R., & Brilliant, S. (2004). Primary health care teams: Team members’ perceptions of the collaborative process. Journal of Interprofessional Care, 18(1), 75-78.
Note: Retrieved from the Walden Library databases.
This article reports the results of an experiment to measure the impact on a variety of providers working on a collaborative health care team in a noninstitutional, community setting.
Fewster-Thuente, L., & Velsor-Friedrich, B. (2008). Interdisciplinary collaboration for healthcare professionals. Nursing Administration Quarterly, 32(1), 40-48.
Note: Retrieved from the Walden Library databases.
This article considers a number of factors that can help or hinder the cause of interdisciplinary collaboration, especially those associated with patient outcomes. This is an especially important matter as it has been estimated that nearly 70% of adverse effects suffered by hospital patients are caused by the lack of communication and collaboration between doctors and nurses.
Grumbach, K., & Bodenheimer, T. (2004). Can health care teams improve primary care practice? JAMA, 291(10), 1246-1251.
Note: Retrieved from the Walden Library databases.
The authors identify and discuss five essential characteristics that teams must possess to work together successfully, namely: defined goals, clinical and administrative systems, division of labor, training, and communication. Case studies of a local and a regional primary care practice are used to advance the argument.
Hennessy, C. (2010, January 7). Hospice provides compassionate end-of-life care. CT Post. Retrieved from http://www.ctpost.com/health/article/Hospice-provides-compassionate-end-of-life-care-312784.php
When we think of interdisciplinary health care, we generally wouldn’t think of hospice. But, as this article demonstrates, hospice care is a perfect example of the coordinated, compassionate, and efficient model of providing needed health care services.
Huang, B., & Perroud, T. (2003, January 17). Our protocol for a successful interdisciplinary collaboration. Science Career Magazine. Retrieved from http://sciencecareers.sciencemag.org/career_magazine/previous_issues/articles/2003_01_17/noDOI.11449521753182219153
Two physical chemists describe the benefits of collaboration in their lab research. While their work has no direct bearing on health care, their observations and experiences collaborating with others provide useful lessons that can be applied to any endeavor.
Leaders of major national organizations collaborate on approaches to health reform. (2009, March 27). Targeted News Service.
Note: Retrieved from the Walden Library databases.
This press release announces the formation of a task force committed to cooperating to find solutions to difficult issues involved in reforming the nation’s health care system. The intent is to facilitate the process in a nonpolitical way. The committee is composed of leaders representing different industry stakeholders in the process, including doctors, hospitals, insurers, consumers, and public health professionals, among others.
Mitchell, G., Tieman, J., & Shelby-James, T. (2008). Multidisciplinary care planning and teamwork in primary care. Medical Journal of Australia, 188(8), 61-64.
Note: Retrieved from the Walden Library databases.
Systematic reviews of research on the effect of a multidisciplinary approach to treating patients with chronic disease confirmed that such an approach improved patient outcomes. Before it can become widespread, this approach will require structural and practical realignment.
Senators urge review of barriers to collaboration. (2010, January 11). AHA News, 46, 1.
Note: Retrieved from the Walden Library databases.
In an effort to expedite and encourage the adoption of collaborative care models for patient-centered health care, nine Democratic U.S. Senators petitioned the Department of Justice and the Federal Trade Commission to create guidelines and offer advice to hospitals, doctors, and other interested care providers.
State Government of Victoria Department of Health. (n.d.). Achieving best practice cancer care, A guide for implementing multidisciplinary care. Retrieved from http://docs.health.vic.gov.au/docs/doc/Achieving-best-practice-cancer-care–A-guide-for-implementing-multidisciplinary-care—Mar-2007
This site presents a model for multidisciplinary cancer care in the state of Victoria, Australia.
Taylor, T. (2009). The role of community-based public health programs in ensuring access to care under universal coverage. Issue Brief. American Public Health Association.
“The Role of Community-Based Public Health Programs in Ensuring Access to Care Under Universal Coverage” by Tia Taylor. Copyright October 2010 by AMERICAN PUBLIC HEALTH ASSOCIATION. Used by permission of AMERICAN PUBLIC HEALTH ASSOCIATION via the Copyright Clearance Center.
This monograph published by the American Public Health Association addresses the importance of community-based public health programs and how the rising tide of health reform may, in fact, jeopardize some essential services, putting already vulnerable populations at greater risk.
U.S. Department of Health and Human Services. (2010). Recovery Act (ARRA): Community health centers. Retrieved from http://wayback.archive-it.org/3909/20130926130202/http://www.hhs.gov/recovery/hrsa/healthcentergrants.html
As part of the American Recovery and Reinvestment Act, $2 billion was designated for the creation of Community Health Centers. Some of the key provisions of the program are provided on this site.
Vazirani, S., Hays, R., Shapiro, M., & Cowan, M. (2005). Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. American Journal of Critical Care, 14, 71-77. Retrieved from http://ajcc.aacnjournals.org/content/14/1/71.full.pdf+html
Perhaps the most compelling argument for interdisciplinary health care is that it has been demonstrated to improve patient outcomes. This article describes a 2-year experiment to measure the effect of a multidisciplinary intervention on health care providers at an acute inpatient medical unit.
U.S. Department of Health and Human Services. Increased demand for community health center services (IDS) grants by state. Retrieved from http://wayback.archive-it.org/3909/20130926131407/http://www.hhs.gov/recovery/programs/hrsa/ids.html
This website keeps a constant running count of the effect of new grants for community health services under the American Recovery and Reinvestment Act of 2009. The number and value of grants, jobs created, and patients covered is tabulated by state.
Click on your state to look for the grants in your state.
Community Medicine and Community Health Centers
U.S. Department of Health and Human Services. Recovery Act funding for commmunity health centers. Retrieved from http://wayback.archive-it.org/3909/20130926130349/http://www.hhs.gov/recovery/programs/hrsa/index.html
This page provides links to ARRA Community Health Center grants by state.
Find an example of community centers in your state.
The University of Texas Southwestern Medical Center at Dallas. Family and Community Medicine, Division of Community Medicine. Retrieved from http://www.utsouthwestern.edu/education/medical-school/departments/family-community-medicine/divisions/community-medicine/index.html
This is the website for the Department of Family and Community Medicine at the Southwestern Medical Center in Dallas, TX. Explore the site to familiarize yourself with the kinds of services and research being conducted here, as it relates to an interdisciplinary approach to community health.
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Current Issues in Healthcare Policy and Practice
DISCUSSION BOARD 250-300 WORDS DUE THURSDAY
Discussion: Access to Care
One of the biggest complaints about the U.S. health care delivery system revolves around access to services. More specifically, too often, the high cost of health care is a barrier to its access. A key objective of health care reform efforts has been to expand access to quality care to more people. What will the effects of increasing access to health care be?
To prepare for this Discussion, consider this week’s Learning Resources.
Find an article in the Walden Library that illustrates the potential positive and/or negative impact of increased access to health care services as a result of health care reform.
Post a comprehensive response to the following:
- Cite and summarize the article.
- What are two effects of increased access to care on the providers of that care (i.e., hospitals, physician practices, or long-term care facilities)?
- How do you think the impact of increased access might be mitigated? Should it be? Why or why not?
Note: Initial postings must be 250–350 words (not including references).
_____________________________________________________________________
ASSIGNMENT …. DUE SUNDAY BY 11:59 PM (CITE ALL REFERENCES IN ASSIGNMENT)
The Practical Role of Policy
What has health policy done for me lately?
Developing health care policy is often an exercise in balancing competing interests, many of them political. Policy is often the product of elaborate negotiations between many interested parties. It is sometimes difficult for individuals to see the connection between health care policies and their own personal health. In short, people ask, “What does health policy mean to me?”
This Application will give you an opportunity to delve a little deeper into the practical role of policy, by examining a health policy issue that is of particular interest to you.
To prepare for this Application, select an acute or chronic health issue (such as motorcycle accident-related head trauma or type 2 diabetes) that is of interest to you. Using the Walden Library and credible websites, research this issue to analyze a key policy related to the health issue you selected. Select at least three articles about the policy to use in your paper.
To complete this Application, write a 3- to 4-page paper that addresses the following:
- Describe the health care issue you selected. Explain why this issue is important, in terms of access, affordability, quality, and safety.
- Identify a health policy that is related to the health issue you selected. Explain its intended purpose and indicate the source of the policy (i.e., state law, federal law, accreditation organization, etc.)
- Cite and summarize the articles you selected.
- Analyze what the literature says about the impact of the policy, in terms of cost, affordability, access, quality, and safety.
Your written assignments must follow APA guidelines. Be sure to support your work with specific citations from this week’s Learning Resources and additional scholarly sources, as appropriate. Refer to the Essential Guide to APA Style for Walden Students to ensure your in-text citations and reference list are correct.
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RESOURCES
Current Issues in Healthcare Policy and Practice
Chapter 2, “Cost, Access, and Quality” (pp. 45–76 through “Current Indicators of Access”)The cost of health care, access to it, and the quality of the care are often related to one another in a reciprocal and interactive way. This chapter establishes a foundation for understanding health care costs and how those costs are directly related to access and quality. You will finish this chapter in next week’s reading.
Health Politics, Policy, and Practice
Chapter 5, “Medicare: The Great Transformation”Along with Medicaid and Social Security, Medicare is one of the three largest Federal entitlement programs. It is relied upon by millions of American citizens. This chapter looks at the history of this important program and how the politics influence the benefits and operation of this mammoth government program.
Chapter 6, “Medicaid: Health Care for You and Me?”This chapter presents an overview of the Medicaid program, looks at how it has evolved over the years, and considers where it might be going. It presents three commonly held myths about Medicaid.
Goldsmith, J. (2010). Analyzing shifts in economic risks to providers in proposed payment and delivery system reforms. Health Affairs, 29(7), 1299–1304. Retrieved from http://ezp.waldenulibrary.org/login?url=http://proquest.umi.com.ezp.waldenulibrary.org/pqdweb?did=2089628041&sid=6&Fmt=3&clientId=70192&RQT=309&VName=PQD
The unbridled growth of health care costs has been, and continues to be, a significant factor fueling the push for health care reform. This article analyzes some of the cost-containment models that are currently under consideration and assesses the feasibility of their implementation.
Rosenthal, E., Brownstein, J., Rush, C., Hirsch, G., Willaert, A., Scott, J., et al. (2010). Community health workers: part of the solution. Health Affairs, 29(7), 1338–1342. Retrieved from http://ezp.waldenulibrary.org/login?url=http://proquest.umi.com.ezp.waldenulibrary.org/pqdweb?did=2089628121&sid=9&Fmt=3&clientId=70192&RQT=309&VName=PQD
This article examines the contribution that community-health workers could make to cost reduction, access expansion, and quality improvement of Medicaid and health care, in general.
Heathcare.gov. (n.d.). Understanding the affordable care act. Retrieved October 18, 2010, from http://www.healthcare.gov/law
This web page presents various elements to provide an overview of the Affordable Care Act. Signed into law by President Obama on March 23, 2010.
Optional Resources
“Health Care Reform” (PBS.org)
http://www.pbs.org/now/shows/health-care-reform/
Current Issues in Healthcare Policy and Practice
Chapter 9, “Long-Term Care Reimbursement”
Kristof, N. D. (2010). Access, access, access: [Op-Ed]. The New York Times (Late Edition), A31. Retrieved from http://ezp.waldenulibrary.org/login?url=http://proquest.umi.com.ezp.waldenulibrary.org/pqdweb?did=1985614601&sid=2&Fmt=3&clientId=70192&RQT=309&VName=PQD
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