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¶ … RCA) is to simplify the problems at hand it is a systematic approach that can lead, like a trail of clues, investigators to objective truths or at least well assumed ones. The U.S. Department of Health and Human Services endorsed this method as a practical approach as presented in their agency on research quality. The group acknowledged that "root cause analysis (RCA) is a structured method used to analyze serious adverse events. Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health care. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals."
This essay will address the case study of Mr. B's untimely death and apply a RCA to the facts of the case. The essay will also use change theory to develop an improvement plan to decrease the likelihood of this problem occurring again. Before concluding this essay will also use a failure mode and effects analysis to project the likelihood of failure to changes made to the system. Finally the role of nurses will also be included in this essay and how their essential role of caring is extremely important to the success of any patient's odds of survival. B. injured?
Errors
The simplicity of RCA is reflected in the ability to get at the root cause be applying one simple tool. By simply asking 'Why?' The root cause can be easily identified and the RCA can be accumulated and processed for change. The following questions will highlight the main errors and hazards with the situation:
Why did Mr. B. choose this hospital ?
Why was Mr. B. directed to the ED?
Why was Mr. B. still on painkilling medication ?
Why was Mr. B. administered increasing amounts of pain medication ?
Why was the patient in so much pain ?
Why did the staff seek to numb his pain so readily ?
Why is pain relief a top priority ?
Why is Dr. T. working in the ED ?
Why isn't their more staff working in the ED ?
Why was Mr. B's hip manipulated ?
Why was the patient considered brain dead ?
Why did the family choose to remove life support ?
It appeared that many errors could and may have occurred. It appeared from the case study that there were too few nurses on staff and definitely not experienced enough to be handling such high stress cases in the ED. Mr. B's misdiagnosis also appears to be the problem as a more reasonable approach to understand his problem would have been realized after the pain medicine began to not have an effect.
Improvement Plan with Change Theory
Nursing Change Theory is based in the ideas of Lewin who suggested that three major forces drive transformation. These include the driving forces, the restraining forces and the equilibrium. "They facilitate change because they push the patient in a desired direction. They cause a shift in the equilibrium towards change. Restraining forces are those forces that counter the driving forces. They hinder change because they push the patient in the opposite direction. They cause a shift in the equilibrium that opposes change. Equilibrium is a state of being where driving forces equal restraining forces, and no change occurs. It can be raised or lowered…
References
Burnes, B. (2004). Kurt Lewin and complexity theories: back to the future?.Journal of change management, 4(4), 309-325.
Eriksson, K. (1996). Understanding the world of the patient, the suffering human being: The new clinical paradigm from nursing to caring. Advanced Practice Nursing Quarterly, 3(1), 8- 13.
Riehle, M.A., Bergeron, D., & Hyrkas, K. (2008). Improving process while changing practice: FMEA and medication administration. Nursing management,39(2), 28-33.
US Department of Health and Human Resources (nd). Agency for Helathcare Research and Quality. Root Cause Analysis. Viewed 19 Mar 2005. Retrieved from http://www.psnet.ahrq.gov/primer.aspx?primerID=10
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