Ensuring Patient Safety Through RCA Procedure

¶ … Mr. B. was left in his room without appropriate monitoring following the administration of diaxepam and hydromrophone in order to permit reduction of his hip following a fall. The 67-year-old Mr. B. presented with several health concerns in addition to his recent fall that injured his hip. was on a regimen of oxycodone for chronic back pain and atorvastatin, presumably for elevated cholesterol and lipids, has impaired glucose tolerance and prostate cancer. His injury notwithstanding, Mr.

B.'s overall health was not optimal at the time of admission, and included risk of heart problems. The hospital policy for moderate sedation / analgesia or conscious sedation was violated. According to the policy, Mr. B. should have received continuous monitoring of B/P, ECG, and pulse oximeter throughout the procedure and until he met the specific discharge criteria, which include: fully awake, VSS, no N/V, and able to void.

An experienced critical care nurse trained in the conscious sedation policy and procedures -- and in Advanced Cardiovascular Life Support (ACLS) -- was available at the time of Mr. B.'s admission and procedure. Several patients were admitted in quick succession during the recovery period of Mr. B. The nurses and the physician were occupied with the newly admitted patients, both of whom require close and immediate attention. Back-up staff was available during this period of time. B.

Physicians must be alert to concomitant problems when typical doses of medication are inadequate and increased doses are required to achieve treatment. This caution applies particularly to the use of drugs for sedation and muscle relaxation, such as diazepam, hydroorphone, and similar drugs. Indications that a patient is at risk for complications during a routine treatment shall trigger implementation of the more cautious policy and procedural route, regardless of the actual severity or risk of the procedure the patient is undergoing.

In other words, the physician is to err on the conservative side and communicate an appropriate set of directives to the nursing staff that reflect his or her concerns and cautious position. Nurses who perceive the same set of conditions and are similarly concerned are to communicate directly with the physician regarding possible precautions that may be employed. The importance of appropriately implementing hospital policies is stressed. C.

Both an RCA and a FEMA will be conducted to ensure that the probability of a sentient event such as that which befell Mr. B. is exceedingly low -- and that the improvement process itself will not fail. All resident hospital staff will be included in the FEMA discussion and, since the hospital is a small rural facility, regional support may be requested at the RCA and FEMA meetings and subsequent recalibration trainings. C.1.

Intervention testing to improve the quality of care in the future can take the place of action research with resident staff making changes according to an agreed upon plan of action, and integrating measurement of those changes and the degree of desired outcomes achieved as a result of the controlled change. When creating an improvement action plan, the developers will prefer actions or remedies that are considered to be stronger and more longer lasting over those actions or remedies that have been shown to less enduring impact.

For instance, stronger change actions include implementation of human engineering factors that are permanent and have a physical base, while weaker implementation focuses on procedural changes that can be temporary, such as increased vigilance. C.2. The CEO or Facility Director initiates the process; this ensures that there is awareness and leadership from the top down to the team. Ways to disseminate sharable information and to provide training for stakeholders are identified.

The member of the team are identified and notified; the roles assumed by the members of the team are articulated and team members commit to the various roles. C. 3. The Safety Assessment Code (SAC) score will be used to assess risk and generate an estimate of both the actual consequences that have occurred and the potential consequences that could occur ("Quality One"). The SAC is especially useful in medical settings as it can be used to identify close calls that make system level vulnerabilities salient --.