Organizational Systems and Quality Leadership Essay

A. Complete a root nonplus analytic thinking that restitutions into consideration causative factors that guide to the sentinel event. (This tolerants pop outcome) The terms failure analysis, incident investigation, and root ca occasion analysis atomic number 18 using upd by organizations when referring to their problem solving approach. no matter of what its c eithered in that respect are triplet basic questions to every investigation1. Whats the problem(s)?2. Why did it happen? (the causes)3. What circumstantial every(prenominal)y should be d nonpareil to prevent it? (Galley, n.d., 1)In the subject of Mr. J, these were multiple issues that led to and contributed to his unexpected demise after what is normally considered a routinely per trunked procedure in an emergency section setting. The JCHAO (Joint Commission on Accreditation of Health trade) defines a sentinel event as an unexpected come onrence involving death or serious physical or psychological injury, (Frain , Murphy, Dash, & Kassai, 1) and in the deterrent example of Mr. B, his death would be considered a sentinel event which would warrant a review by a team of interdisciplinary members of the hospital. In this particular fortune members of the team would let in iodin or more ED physicians, the RN in the scenario and the LPN, a respiratory therapist, a nursing supervisor, a hospital administrator, the ED nurse manager, a hospital pharmacist, and a risk manager. More provide nurses from the ER could also be involved. A credible and successful root cause analysis leave al wholeness identify all of the elements that contributed to the event, an action syllabus go out be developed to prevent the event from re leadring and ensure that those actions are completed.Action plans should be based on best practices and appropriate standards. (Frain et al., 10) The scenario presented starts out as whatappears to be an average afternoon shift in a small 6 return a go at it emergency depa rtment in a rural hospital. Staffing consisted of one emergency room physician, one registered nurse (RN), on licensed practical nurse (LPN) and a secretary. Due to the size of this particular ER, in that respect appears to be limited staffing and therefore limited resources to handle large volumes of forbearings and or critical forbearings. at that place are two endurings already organism worked up in the department at the season of Mr. Bs arrival and they are stable, give birth already been evaluated and they are awaiting just treatment or orders. Mr. B is brought to the ED by private vehicle complaining of left leg and hip pain after losing his balance and fall over his dog. The triage nurse noned that other than the patient displaying tachypnea, his vital signs were otherwise within normal limits.The patient states his pain level is severe, a ten out of ten, and physical examination finds a shortened left lower extremity with calf swelling and ecchymosis. In triage i t is noned that the patients leg is stabilized and he is subsequently moved into a patient room where the admitting RN, Nurse J, takes over and gets a more thorough history of this patient, noning impaired glucose tolerance, prostate cancer and continuing back pain. Mr. B regular medications include Atorvastatin and also Oxycodone for his chronic back pain. The doses and how often he takes these mediations is not go outd. Although there is no watch over of both radiology studies existence per salmagundied on Mr. B after his arrival, it is assumed that this was performed in the lead the ER physician completed his evaluation and ordered 5 mg endovenous diazepam to sedate the patient to perform a manual reduction of a dislocated hip. After waiting for 5 legal proceeding, the physician then instructed the RN to administer 2mg of hydromorphone hydrochloride, a powerful narcotic analgesic.The staff waits five more minutes, after which the physician then instructs the RN to repea t both doses of diazepam and hydromorphone because he is not satisfied with the patients level of drugging. It is after these medications are administered that the physician notes patients weight and history of opiate use. Five minutes after the last dose of medication is administered a successful reduction of the left hip takes place and the patient remains sedated. The reduction procedure, which initially began at approximately 1605, ended at 1630. Although Nurse J is monitoring this patient, she is alerted that EMS (Emergency Medical Services) is bringing in an elderly patient with reported discriminatingrespiratory distress. Nurse J, an experienced critical care nurse, elects to place Mr. J on an automatic blood pressure machine with a pulse oximeter.Although not stated, it is likely that this is a portable machine and is not hooked up to any wall monitors. It does not shake off continuous EKG monitoring. It does not mother end tidal CO2 monitoring. Nurse J then elects to lea ve the patient in the company of his son with a blood pressure of one hundred ten/62 and an type O saturation of 92% on the portable machine. The patient is breathing room air and does not have any other monitoring. The ambulance patient has arrived to the department and both the RN and LPN are involved in stabilizing this new arrival and discharging the previous patients as the lobby is now seemly congested with more patients seeking care. There is no mention of anyone suggesting that additional staff should be brought in to attend to with the load. During this time the pulse oximeter alarm fires finish off in Mr. Bs room showing at saturation of 85%.The LPN enters the room and resets the alarm and repeats a blood pressure, but there is no mention of the LPN assessing the patients respiratory and or mental status. At 1643, al some forty minutes after Mr. Bs procedure had begun, the son who is at the bedside with him states the monitor is alarming. Nurse J finds a Mr. B in respir atory arrest and a stat code is called. A code team arrives and the patient is connected to a cardiac monitor for the first time.The patient is in ventricular fibrillation, CPR is begun, and according to this scenario he is intubated to bring forth with he is defibrillated. After thirty minutes of interventions, this patient is resuscitated to a normal sinus rhythm with pulses, but is unable to breathe without a ventilator. He has fixed and dilated pupils and no spontaneous movements. Most likely collectible to the facility being a small rural hospital, they must transport this patient to a higher level of care, and he is flown out to another facility where the patient was ultimately determined to have brain death and was taken off of emotional state support.A-1 Discuss the errors or hazards in the care in this scenario Causative factors in this scenario appear to include poor staffing to patient ratios, inadequate adherence to hospital form _or_ remains of government for mode rate sedation, and an obvious lack of discourse mingled with peers /coworkers. The human factors point to failure of staff to follow an established discourses protocol, possiblefatigue, possible inability to heighten on the task, and a lack of utilizing critical thinking skills. There did not appear to be any equipment problems other than the fact that the appropriate equipment that was in stock(predicate) was not accessed. The surroundingsal nature of emergency medicine lends itself to hazards in the fact that a department can go from being quiet and mellow in one moment, to being volatile and hectic the next moment. It is an environment of unpredictability and bestows care to a wider population of patients than any other department in the hospital.Common environmental issues to all emergency rooms can include poor location and accessibility of equipment, overhead paging systems that no one hears, security risks, lighting and lay issues, lack of privacy due to patients bei ng placed in hallways and other open areas not designated as patient care areas. Organizational factors whitethorn include budgeting limitations, staffing to patient ratios and contingency problems. Dealing with unexpected sick calls, inability to fill those calls, power outages and electronic documentation systems that fail, external environmental disasters, rapid influxes of unexpected patients and the media are all common factors that can disrupt hospital care. Well written policies are a must to guide staff in continuing to provide character care while minimizing errors and hopefully avoiding sentinel events.Potential hazards and errors can be avoided by learning from the literature and past experiences of other emergency departments. circumstantial protocols for procedures performed in the ER are developed for this very reason. In the given scenario there is the issue of proper staffing which take in up a hazard to the patient who at last expired. Nurse to patient ratios i n this scenario were inappropriate due to the fact that a patient who had received moderate sedation was not closely monitored and ideally should have received one on one nursing care for the duration of his procedure and until he met discharge criteria. This would have been possible had the RN asked for back up which was apparently available. Looking back on the scenario, it was noted that immediately after the joint reduction of Mr. B had been performed, a critically ill ambulance patient had arrived and the RN was prudent for that patient as well.In the emergency department, or any department for that matter, nurses are continually subject to frequent interruptions, the need to multi-task, and reliance on work-arounds because of inadequate systemssupport. (Cherry & Jacob, 2011, p. 473) In the case of nurse J, she may have been fixated on completing other tasks, such as stabilizing the ambulance patient, thus distracting her from the ongoing developments with Mr. B. who appeared to be resting comfortably with his son at the bedside. Assuming the patient was safe with a family member, the RN missed the opportunity to reverse the downslide of events that unfolded. Not anticipating the need for additional help is a hazard when staff become overwhelmed but continue to proceed as if help is not needed, because they may be accustomed to being understaffed and working only with what they have. Therefore, this presents the issue of the culture of safety, or lack thereof. It did not appear that there was any organized culture of safety and the communication between staff members appeared to be minimal.Possibly there was an environment of distrust between coworkers, or an intimidating environment in which the RN was afraid to speak up to the ERMD regarding the management of the patients pain and sedation. Perhaps the LPN was intimidated by the RN and did not chose to inform the RN of the abnormal vital signs. It appears that inconsistent or absent communication skil ls among the staff present that daytime contributed overall to a hazardous situation. And lastly, possible poor training and education of staff creates a hazardous environment and the lack of critical thinking skills demonstrated in this scenario suggests that this is an area that necessarily to be examined closely at this hospital. There is no mention of what the LPNs responsibility is in assessing the patient but it is difficult to comprehend how an experienced health care worker in an ER would not investigate a poor pulse oximetry reading further than simply resetting the monitor.Educational requirements and experience of the staff needs to be reviewed and revised by the interdisciplinary team as part of the improvement plan. Errors made in this scenario that contributed to this sentinel event include the fact that there was a specific protocol for witting sedation and it was ignored. Although Nurse J was ACLS (advanced cardiac animation support) certified, and she had complet ed the hospitals training module, she did not follow the guidelines in the written protocol which more than likely would have prevented any of this event from happening. Perhaps she did not understand the protocol, perhaps she was accustomed to taking short cuts, or perhaps she was drug or alcoholimpaired. Another possibility is that the nurse was not able to find the online protocol on the hospital portal. Perhaps the portal was difficult to navigate and the form _or_ system of government was difficult to locate. Being under time constraint, a nurse business leader decide to forgo looking up the policy because it is too time eat to look for it. Only Nurse J. would be able to provide us with this critical information.It is not clear as to why an experienced critical care nurse with no history of negligence did not follow proper procedure. Other errors include the fact that sufficient monitoring equipment was available and not utilized, including use of supplemental oxygen and pos sible end tidal CO2 monitoring. Furthermore, no one in the department called for any back up, such as a nursing supervisor or a respiratory therapist to help manage the patient. The ER physician who ordered the medications did not communicate with the nurse before the procedure about the risks associated with this patient, including the patients home use of opiates for his chronic pain. Polypharmacy, possible use of supplements, adherence issues, and the potential for uncomely drug events all posed potential hazards that needed to be addressed. (Williams, 2002, 1)The RN did not question the physician about the orders and the physician in turn, did not question the nurse if she had any concerns. There was no time-out procedure performed by the staff, which would have given staff members the opportunity to parting concerns. The doctor also failed to notice that the patient was not being appropriately monitored, and along with the rest of the staff he did not appear to display a tea mwork mentality.The key to a successful root cause analysis is to search for answers as to what system errors and failures need to be corrected, and not to pursue blame on any one individual. Individual blame centers around forgetfulness, inattention, or moral weakness. It is punitive. A systems approach examines the conditions under which health care workers work and sets up defenses to avert errors or mitigate their effects. (Cherry & Jacob, 2011, p. 473) The goal is to bring staff together to design and implement offsetes that provide uniform standards of treatment and care and provide safety to all involved and asperse the likeliness of harm or a sentinel event.B. Improvement PlanBy requiring the staff of the emergency department to reexamine its actions on that day, a dialogue is created that hopefully leave create a strong motivation to seek out better and newer ways to handle patients that require sedation and monitoring. If the participation is not there, then the motiv ation will not be created and exchange will not occur. One way of develop an improvement plan would be to apply the theories of change developed by physicist and affable scientist Kurt Lewin in the 1950s.His change management model, known as Unfreeze-Change-Refreeze, refers to a three stage extremity of transitioning through change. Lewin look atd that to begin any successful change process, one must first understand why the change must take place, and this is where the motivation for change begins. He stated that one must be helped to examine many cherished assumptions about oneself and ones relations to others. This is the stage known as unfreezing. (Thompson, n.d., p. 1)In the case of the emergency department, the entire team needs to be compelled to change the way sedation procedures are performed, as well as how patients are handled before and after the procedure. In addition to reviewing the procedural sedation protocol, the team needs to look at overall hospital care of those receiving any medications that cause respiratory depression. This should not be too difficult to elicit since the procedure performed that fateful day resulted in harm and subsequent death of a patient. Not only was the patient and his family harmed, the entire organization was harmed and is liable for this incident. The hospital and its emergency departments community reputation is going to suffer. Knowing that the staff that day is probably emotionally traumatized and possibly fearful of the consequences, the environment is practiced for change and the unfreezing stage can begin with a review of the sedation policy and why it was not followed.Each individual there and staff that were not there that day need to be made aware and can meet one on one with the department manager to voice their concerns and questions. Barriers hopefully will be identified as to why the sedation protocol was not followed that day. The hospital already provides an electronic educational module o n sensible sedation procedures which would have a required date for staff to complete. This module should be reviewed for any inconsistenciesand updated and it should be made easily accessible on the ready reckoner portal. The actual written policy should also be easily accessible on the portal as well as in print form in a binder at the nurses station, should staff not have access to the computer. An analgesic protocol could be developed in which there would be a minimum time lapse between opioid doses (for instance 10 minutes versus 5) and the use of a hospital approved sedation scoring system should be in place.Patients in addition to requiring continuous pulse-oximetry monitoring should also be on continuous end tidal CO2 monitoring as well, long considered a more effective way of measuring effective ventilatory status. A new electronic training module on the use of end tidal CO2 monitoring would be required for nursing staff to complete and equipment in the ED would be upgra ded to provide for this type of monitoring. A representative could come and demonstrate the use of this type of monitoring and sign off employees for a mini-education module.Although many emergency departments have upgraded their documentation to all electronic, it might be helpful for staff nurses who are continuously monitoring patients at the bedside to use paper forms to document the pre procedure requirements including consents, time-outs, intra procedure medications and response to those meds and vital signs as well as post procedure Aldrete bulls eyes and recovery notes. This would be advantageous for simply the reason that not every bed has access to a computer.Health care providers certified in Advanced Cardiac Life Support (ACLS) must be in direct attendance with the patient passim the entire course of the sedation and until the patient is fully recovered. Their primary responsibility is to monitor the vital signs including heart rate and rhythm, blood pressures, respira tory rate and oxygen saturation, as well as the patency of the patients airway. The RN managing the patient should never leave the patient unattended or engage in tasks that would compromise this continuous monitoring. The RN is responsible for taking the leading role in assuring that the care provided is safe. Proper airway equipment and drug reversal agents should be at the bedside and this must be documented. In order to unfreeze the staff and help them to change their behaviors, the ED could hold mock sedation procedures to practice their skills in managing a sedated patient.Annual skills days should be held withreview of the policy and equipment use. Staff would be signed off annually on this module. Certifications for BLS(basic life support), ACLS, PALS(pediatric advanced life support) and possibly TNCC (trauma nurse core curriculum), should be up to date and the hospital should offer these courses on campus to make it easier for their employees to maintain their certification s.Staff members whose scope of practice do not require them to practice ACLS or PALS should be reeducated on what normal vital signs are, how to set parameters on the cardiac monitors, how to take vital signs on the cardiac monitor and they need to review basic BLS skills by attending their own skills day. T separatelying should include basics on what normal vital signs are for polar age groups, and how medications can alter these vital signs. If the hospital has the funds to open a simulation lab, all nurses and allied health personal could practice faux scenarios on mannequins and even videotape them. This would be a huge asset for the staff of all the patient care departments.Another part of the improvement plan would include classes for staff on communication and critical conversations. Learning how to communicate as a team and voice concerns about patient safety is a skill that requires practice, confidence and no fear of retribution or intimidation. Staff members who deal in stressful and hectic environments may at times be uncertain when they see behaviors that are unsafe and therefore may elect to say nothing when they believe the care of a patient may be compromised. In the case of the LPN who turned off the SPO2 alarm, I would wonder if perhaps there was a communication barrier between her and the RN and or the MD, or was it simply a knowledge deficit.An action plan needs to be in place for a saturated emergency department in which additional staff can be called in with a less than 30 minute wait time, or perhaps float other available qualified staff from other departments, such as the critical care unit or the telemetry floor. Because critical care nurses are accustomed to working in a 11 environment with their patients, it would have been ideal to float a CCU nurse to the department when Nurse J realized she could not take care of the rest of the department without leaving Mr. B unattended. Of course this may not havebeen feasible since we do not know the census in the CCU. Chart reviews are also an invaluable tool for improvement.The manager will assign nurse in the ED to perform a monthly scrutinise of all sedation charts with checklists of what was done correctly and what was not. These audits are important for providing data on how the ED needs to improve its performance and safety measures. This data will be provided not only at ED staff meetings but at quality improvement meetings involving the nursing coach and hospital administration. If there is a problem convincing the hospital to provide safe staffing levels, the ED must provide strong data in order to show administration that there is a need to provide additional nursing.After the uncertainty of the unfreeze stage has occurred, change then begins to take place. Staff will start to believe and act in ways that support the new growth of the department. The transition will not happen rapidly as good deal take time to learn and embrace new ways of doing things an d for all(prenominal) individual the rate of change is personal. In order to accept the new change and contribute to its success, staff will need to understand how the changes will benefit them and not every person will ascertain this way. Most health care workers probably savour that if healthcare delivery is made safer and better for their patients, then they will buy in to the need for changes and produce those changes.Unfortunately some of these people may feel harmed by change, and it is possible to notice some folks not participating in meetings, outside events, or educational updates. They may voice discontent with the whole process and complain that the changes are unnecessary. They may feel the status quo is being challenged and are threatened if they are unable to adapt to the changes. They may eventually leave the department or even the hospital environment as a whole. These are the people who may require the most encouragement and handholding to get them through the transition. clock time and communication are of utmost importance and as staff gains understanding of the changes, they also need to feel connectedness to the organization throughout the transition period. (Thompson, n.d., p. 3)Lewins third stage of change, or Refreezing, takes place when the organization has identified the barriers to sustain the changes made, and when it has identified what makes the changes work. Employees feelconfident and comfortable using new communication techniques, they participated in learning the new procedures and feel supported by their peers and leadership. There is an established feedback system for employees to participate in regarding their education and training, in which they can voice what full treatment and what doesnt. Changes are now used all of the time and are incorporated into the normal day to day operations in the ED. If the changes are not used regularly and not anchored in to the culture of the ED, the refreezing state cannot occur an d employees may get caught in a transition state where all(prenominal) person is not sure how things should be done and there is no consistency for policies and procedures being followed.For the refreezing states to be successful, the department should celebrate its success with the change. Employees will need to have a sense of closure and management needs to help them feel appreciated for enduring an uncertain and uncomfortable time. It is important to encourage staff to believe that the contributions they have made have made the changes a success. (Thompson, n.d., p. 4) Continuing to provide support and transparency keeps employees informed and motivated to preserve the new changes in place. Allowing staff to voice their opinions and participate in how changes are rolled out is part of this process. Overall, a team approach to care is of utmost importance in the ED and each individual should be encouraged and reminded regularly how important their contributions are to the whole. Reward systems to encourage pride and enthusiasm for work well done can be include at monthly staff meetings. One or two employees might receive a gift or a trophy for stark work, these recipients would be nominated by their peers who anonymously write a nice note about someone who did something nice for a patient or a staff member or just did a particularly great job that day. Team building activities can also include an organized act outside of the ED where employees and their family members can socialize together and relax. Nursing leaders and managers should strive to build environments that are conducive to friendships, facilitating and promoting good communication and respectful communication between nurses, physicians and administrators. (Blosky & Spegman, 2015, p. 34) Trust is the cornerstone of good communication, which was sorely lacking in the ED that day.C. Use a failure mode and effects analysis to run across the likelihood that theprocess improvement plan you sugges t would not fail. (Identify the members of the interdisciplinary team who will be included in the RCAS and the FMEA)FMEA is a step by step process used to identify all possible failures in a design , a manufacturing or assembly process or a product or a service. FMEA was started by the US military in the 1940s, and was further developed by the aerospace and automotive industries. (American Society for tone ASQ, n.d., p. 1) It has been adopted by the healthcare industry successfully as a tool to identify areas of healthcare processes tat may fail, in order to prevent harm or sentinel events before they occur.Failure modes are the ways, or modes in which something may fail. Failures are errors or hazards, which affect the customer and in healthcare the customer is usually the patient. These errors or hazards can be actual, or potential. Effects analysis is the study of consequences of those failures. Failures are prioritized in order of how severe the consequences are, their frequenc y of occurrence, and their ease of mentionion. The purpose of the FMEA is to pass off or reduce the percentage of failures, starting with the highest priority areas. (ASQ, n.d., p. 1)In the scenario of Mr. B, unfortunately the FMEA cannot change the outcome, but it will be a proactive method of developing a new policy and procedure for how sedation cases are handled in the emergency room setting. The FMEA will be used to evaluate the new protocol for sedation procedures as well as staffing protocols related to monitoring 11 patients. This evaluation will occur before the actual implementation and will be used to assess its impact on the existing protocols.(IHI, 2015, p. 1) The process that needs to be evaluated and improved specifically to the case of Mr. B, would be the moderate sedation policy and its specifics to requirements of staff during the procedure and the recovery period.Some of the failure modes that may occur or have the potential to occur would be staff unsusceptibi lity to change, inexperienced nurses or practitioners with lack of education, inadequate ability to staff the ED appropriately during influx of patients, sick calls, or inadequate equipment or equipment failure. (Study Mode, 2014, p. 12) The key to a successful FMEA will be the involvement of a interdisciplinaryteam, which would most likely consist of the some of the same members of the RCA.An emergency room physician, preferably the director, director of respiratory therapy, the hospital pharmacist, the ED nursing director, a risk manager, a head administrator who can lead the group in decision making, one or two ACLS certified staff nurses from the ED that perform sedation procedures, head of anesthesiology, and possibly even members from other departments where moderate sedation is performed. The team will need to meet regularly and be committed to providing continuing support during the course of implementation.C1 InterventionsWith the unfortunate scenario of Mr.B, it is now up the the interdisciplinary team to begin exam interventions that will or may be integrated in to the new plan for management of moderate sedation patients, with the goal of improving safety and eliminating ill events. Once the established team has focused their aim, their next step would be to test a change or a few changes in the ED. This would be done with subsequent procedural sedation procedures which are commonplace in the ED. A small but major change to test would be the mandatory presence of an ACLS certified RN in 11 care of the patient from the beginning of the procedure and throughout it to discharge.The goal of this change is to prevent adverse events from respiratory depression in 100% of all patients receiving sedation in the following 6 month period. Performing this test several times will enable the team to see if the staff is actually complying with the new protocol and what barriers there are to prevent it from being successful. Staff will give feedback later on a s to what is working and what is not, and what they think needs to be done to make the changes work. An effective way to implement testing would be to utilize a PDSA daily round.The Plan-Do-Study-Act (PDSA) cycle is known as shorthand for testing a change by planning it, trying it, observing the results, and acting on what is learned. (Institute for Healthcare Improvement IHI, 2015, p. 1) jibe to the Institute for Healthcare Improvement, the reasons to teats changes are as follows To increase ones belief that the changes will result in improvement To decide which of several proposed changes will lead to the desired improvement To evaluate how much improvement can be expected from the change To decide whether the proposed change will work in the actual environment To decide which combinations of changes will have the desired effects on the important measures of quality To evaluate costs, social impact, and side effects from a proposed change To minimize resistance upon implementati onThe Institute for Health Improvement lists these steps in the PDSA cycle to includeStep 1 PlanPlan the test or observation, including a plan to collect the data State the objective of the test Minimize or eliminate adverse events from respiratory depression while being monitored in the ED under conscious sedation Make predictions about what will happen and whyDevelop a plan to test the change (Who, what, when where? What data needs to be collected?)Step 2 DoTry out the test on a small scale perchance only perform the test in a 3 week period, on sedation procedures performed between the busiest times of the ED, for example between noon to 6pm. In a 6 bed rural ED, this might actually be the busiest time period. Carry out the testDocument problems and observations, unexpected and expected gravel analysis of the dataStep 3 StudySet aside time to analyze the data and study the results, for example a biweekly or monthly meeting of the FMEA team. Complete the analysis of the dataSummar ize and reflect on what was learnedStep 4 ActRefine the change, based on what was learned from the test. Determine what modifications should be made. Prepare a plan for next test, probably on a larger scale. For example, test all sedations over a month , for actual 24 hour periods in the ED.In addition to performing the PDSA cycles, the ED could appoint a volunteer or volunteers from the department to form a safety committee with a leader being the liaison who would have the authority to come up with quick solutions to certain problems that are encountered in the department on a daily basis. The liaison would take care of fixing broken equipment or replacing it, ordering new equipment and providing user training, communicating with staff about safety concerns and bringing these concerns to management and the FMEA team.The safety liaison would be trained in Human Factors Engineering, the science of why people make mistakes. The staff will need to be reassured that this person is the ir ally and not an informant or disciplinarian. (Institute for Healthcare Improvement IHI, 2015, 1) This is a person they should feel comfortable reporting their concerns to. This person could take an active role in the PDSA testing and collect data as which could be added to the monthly chart audits of all the conscious sedation procedures performed since that fateful day with Mr. B.C2 Presteps Discuss the pre-steps for preparing for the FMEA. Step one in preparing for the FMEA in regards to revising the sedation protocol involves selecting a specific process to evaluate. While there were many factors that contributed overall to the sentinel event that occurred , the FMEA should be focused on a sub process. Conducting an FMEA on a combination of the sedation protocol, the staffing ratio issues, the communication problems between staff members, knowledge deficits of staff and equipment issues would be an overwhelming task, so instead we will consider individual analysis of each var iant. In this case, we are going to focus on creating a better defined policy on how to safely perform conscious sedation in the emergency room setting in order to prevent further sentinel events.We want to define in the policy what licensed and certified forcefulness is to be present and performing the procedure, and step by step spell out what is required of those team members from the time of informed consent to the time the patient is discharged from the ED. The policy needs to be easily accessible and there needs to be a standard way of making sure staff has read the policy and understands how to follow it. The goal is to make sure that the patient has 11 care at all times with qualified staff office and leaves the ED in stable, improved condition. The second pre-step is to recruit the multidisciplinary team, including everyone who is involved at any point in the process. Be clear that not all people need to be included on the team throughout the entire process, but should be part of the discussions in which they are or did participate in the process. For example, In the case o f Mr. B, radiology was probably at the bedside performing pre and post reduction films, in which the RN clearly would not have remained at the bedside unless he or she was wearing a lead apron.Pharmacy may have become involved if they had to mix any post resuscitation drips for the patient after he returned to a sinus rhythm from ventricular fibrillation. The secretary was involved in calling a rapid response team, and members of that team may be able to provide valuable insight as well. The third pre-step is to have the team meet together to create a list of all of the steps in the process. Every step should be numbered and be as detailed as possible. Note that this may take numerous meetings to complete this portion, due to all of the variables and complexities.Using flowcharts helps team members to visualize the processes more clearly and create a more understandable outline of the steps. There needs to be a group consensus that the outlined steps of the FMEA correctly show the process. By creating a step by step flow sheet the team will be able to visualize the scenario in detail and begin the process of elimination of what does and does not work and move on to pre-step 4. The team will now begin to list all of the possible failure modes. Possible failure modes include absolutely anything that could go wrong, such as the following Staff not trained in protocolStaff not knowing how to properly use equipmentMonitor not connected to patientEquipment not plugged inMedications not reconciledCommunication problems between peersAssessments not completedAncillary staff not educatedIV fluids not runningPatient experienced respiratory arrestThese are just of the few of the possible failure modes that could be listed. For each of these failure modes, the team must list a cause. For example, in the case of Mr. B, he was never connected to a cardiac monitor until he went unresponsive, so the team must try and explain the cause of this. Prestep 5 , for each failure mode, the team will need to assign a numeric value which is called the Risk Priority Number or RPN. The RPN is a measurementof three variables the likelihood of the failure occurring, of it being detected, and its severity. This is a scoring method that assists the team in determining what areas need the most most focus on improvement.C3 Three goOnce again, assigning numeric values to three separate variables assists the team in determining the issues which should be prioritized in order of importance, or the need for improvement. The three topics are as follows( IHI, 2015, p. 4) the likelihood of occurrence In other words, how likely is it that this failure mode will happen A score between 1 and 10, with 1 meaning very unlikely to occur and 10 being very likely to occur. In the case of Mr. B, had a FMEA already been in place prior to his visit to the ED, the likelihood of his demise would have been much more unlikely to occur. But the system had failed him and due to all of the multiple mistakes that did occur that day, the likelihood of what happened was higher up on the numeric scale. the likelihood of detection If this failure mode does happen, how likely is it that it will be detected? A score between 1 and 10, with 1 meaning very likely to be detected and 10 being very unlikely to be detected. On the day of Mr. Bs demise, there were multiple opportunities for the staff to detect that there was a potential problem, but they did not. No one noted the lack of staff, communication was poor, and proper equipment was not utilized. So, this question goes back to the Root Cause Analysis and in the FMEA the team will need to determine how the staff can detect these failures before harm occurs again to someone else. the severity If the failure mode happens, what is the likelihood that the patient will be harmed? A score between 1 and 10, with 1 meaning very unlike ly that harm will occur and 10 being very likely that severe harm will occur. According to the IHI, a score of 10 often means death. In Mr. Bs case, the consequence that resulted from thefailures in the ED that day was his untimely death. So the severity rating for that particular day would be a 10.D. Discuss how the professional nurse may function as a leader in promoting quality care and influencing quality improvement activities The professional nurse plays a critical role in hospital quality improvement, since nurses are the primary caregivers in the system of healthcare. They are pivotal in improving the processes in which care is provided. According to Cynthia Barnard, MBA, the role of the professional nurse in quality improvement is two-fold to turn tail out interdisciplinary processes to meet organizational QI goals, as well as measuring, improving and controlling nursing sensitive indicators affecting patient outcomes specific to nursing practices. She states that all leve ls of nurses, from the direct care at the bedside, to the chief nursing officer (CNO), play a part in promoting QI within the healthcare provider organization. (HCpro, 2010, p. 1)Ms. Barnard lists the following levels of nursing and their professional responsibilities The CNO The CNO sets the tone for the nursing departments participation in QI. As an administrator, the CNO is responsible for integrating nursing practices in to the organizational goals for justice in patient outcomes by communicating the strategic goals to all the levels of staff.The nurse manager (NM) or nursing director The NM or director is responsible for communicating and operationalizing the organizations QI goals and processes to the bedside nurse. The NM identifies specific nursing sensitive indicators that need improvement according to the organizations specific patient population and coordinates QI processes to improve these at the unit level. The direct care nurse The bedside nurse is the key to quality patient outcomes, carrying out the protocols and standards of care shown by evidence to improve patient care.Important to this provision of quality care is the fact that professional nursing leaders are the key factor in setting the tone and providing an environment in which all health care staff feel empowered to uphold these expectations. If nursing leadership and administration feel that they have less than adequate engagement of staff, it may be simply because the staff may not always understand the rationale and momentum nates particular quality improvement initiatives. For nurses to be involved in delivering high quality care, it is imperative that leadership allows the participation of staff nurses into the design and implementation of processes by continuously educating and informing them, instead of simply telling nurses what they are supposed to do.A hospital culture that encourages quality as everyones responsibility is most likely to achieve sustained and noticeable impr ovement. Because nursing practice occurs in the context of a larger team, the impact of other departments and practitioners must be included in leaderships efforts to improve quality. (Draper, Felland, Liebhaber, & Melichar, 2008, p. 4) By having every staff member engaged, including the other members of clinical staff, ie physicans, respiratory therapy, even housekeeping and dietetical management, accountability for patient safety and quality becomes a group effort and does not rest mainly on the shoulders of the nursing population.ReferencesAmerican Society for Quality (n.d.). Failure Mode Effects Analysis (FMEA). Retrieved July 3, 2015, from http//asq.org/learn-about-quality/process-analysis-tools/overview/fmea.html Blosky, M. A., & Spegman, A. (2015). Communication and a healthy work environment. Nursing Management, 46(6), 32-38. Cherry, B., & Jacob, S. R. (2011). Contemporary nursing issues, trends and management. Available from https//online.vitalsource.com//books/978-0-323-0 6953-3/pages/52165015 Draper, D. A., Felland, L. E., Liebhaber, A., & Melichar, L. (2008). The rrole of nurses in hospital quality improvement. Retrieved July 3, 2015, from http//www.hschange.org/CONTENT/972 Frain, J., Murphy, D., Dash, G., & Kassai, M. (n.d.). . Retrieved, from Galley, M. (n.d.). Basic elements of a comprehensive root cause investigation three steps and three tools that organize and improve your problem solving capability. Retrieved June 29, 2015, from rootcauseanalysis.info HCpro (2010). use up the expert Understanding nursing roles in quality improvement. Retrieved July 6, 2015, from www.hcpro.com/NRS-248978-868/Ask-the-expert-Understanding-nursing-roles-in-quality-improvment.html Institute for Healthcare Improvement (2015). Failure modes and effects analysis. Retrieved July 3, 2015, from