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Sentinel events are never something healthcare workers or facilities want to have occur. If an unfortunate event does take place, it is necessary to properly investigate the situation in hopes to learn from the event and hinder another episode. The following will discuss procedures used to investigate sentinel events such as root cause analysis, change theory and failure mode and effects analysis using the scenario involving Mr. B in Task 2 instructions. A. Root Cause Analysis

Nursing is a profession of helping others. Those who choose to work in healthcare never intended on harming. However, if harm does come to a patient proper policy and procedure should be followed after the event. “The Joint Commission adopted a formal Sentinel Event Policy in 1996 to help hospitals that experience serious adversed events improve safety and learn from those sentinel events” (“Sentinel Event | Joint Commission,” n.d.). The intention of the root cause analysis is to find the areas in need of improvement for reduction of risk and aid in better patient care.

Mr. B arrived in the Emergency Department with left leg and hip pain. After assessment it was determined Mr. B would undergo left hip reduction under conscious sedation. Mr. B was sedated appropriately with successful reduction. Nurse J and the LPN on staff had no signs of personal issues which led to the adverse event however there was a lack of complex critical thinking skills by both staff members. To begin, Nurse J was following Dr. T’s orders with medication administration. Mr. B’s medical history was reviewed and it was found Mr. B took oxycodone on a regular basis. With the additional IV medication there should have been concern of respiratory depression due to the multiple pain medications administered. This respiratory depression was evident when the LPN entered Mr. B’s room and found his oxygen saturation alarm sounding. Unfortunately, the LPN did not notify either Nurse J or Dr. T of Mr. B’s oxygen saturation of 85%.

The equipment used in Mr. B’s care was found to be in working order. It is not clear if the LPN understood the warnings and alarms since there was no further interventions completed when Mr. B’s oxygen saturation alarm sounded.

There were no uncontrollable external factors such as a natural disaster that added to this event. There was an influx of patients in Emergency Department lobby with the added stress of an anticipated emergency transport patient.

Not having more information regarding the hospitals abilities, unsure if this event could have occurred in other areas of the facility.
The hospital had policy in place for conscious sedation and Nurse J had completed the training module for conscious sedation as well as holding a current ACLS certification. Nurse J was an experienced critical care nurse with clinical evaluations showing she met the requirements of her position. The credentials and training of the LPN on staff is unknown.

Staffing at the time of the event consisted of one RN, one LPN, one secretary and one Emergency Department physician. Respiratory Therapy is on staff, not present, but available if needed. When Mr. B arrived he made the third patient in a six bed Emergency Department. Additional back-up staff was available if needed. Policy for nurse to patient ratio for the facility is unknown however one on one care should have been addressed with the potential for respiratory depression with Mr. B. Additional staff were available to care for the incoming patients but were not utilized. With the issue of one on one care for conscious sedation if the only concern was respiratory related the in-house respiratory therapist could have been paged to monitor Mr. B while Nurse J was caring for other patients.

Knowing Mr. B’s medication history of oxycodone use for chronic pain and the added medication for sedation would most definitely qualify him for one on one care until discharge criteria were met due to the potential for respiratory depression. With the added stressors of an additional critical patient arriving for care and multiple patients with need to be seen in the Emergency Department lobby the back up staff should have been utilized.

Communication during the event was lacking. Verbal medication orders were given by Dr. T and were followed through by Nurse J however there was no professional communication between the two healthcare providers on the possible consequences of respiratory depression with multiple medications being administered. This was followed by the LPN on staff not making Nurse J aware of the decreased oxygen saturation she was witness to when she reset Mr. B’s alarm. The department as a whole did not communicate with the organization for the need of assistance with the influx of patients. Although, the staff did not communicate well it is unclear what the overall culture is within the organization. The lack of discussion could be attributed to peer intimidation or barriers in an open communication policy.

B. Change Theory
Reading the scenario of Mr. B, it appears the staff were attempting to care for the patients in the Emergency Department to the best of their ability. From the perspective of the reader there are factors relating to care that need change. Change is always difficult and sometimes hard to have accepted and implemented. To help with this transition Kurt Lewin’s change theory can be used. “Kurt Lewin theorized a three-stage model of change that is known as the unfreezing-change-refreeze model that requires prior learning to be rejected and replaced” (change theory, 2015, p.1). In regard to the sentinel event with Mr. B, to begin the process of change the facility needs to present the case in a way that others know change should occur so another such event does not occur.

Having the ones directly involved with Mr. B’s care presenting a video or sending out company wide e-mail explaining their involvement in the situation could give a personal perspective to others. Of course, this needs to be done in a positive, professional manner that does not leave any blame on a single individual primarily using it as a learning device for others. There should also be open communication on the event so there is evidence there is need for change. This would include answering all questions as to why the change must occur. Although this is sometimes the most difficult stage in change, making one deviate from what they feel is norm, if handled appropriately and productively can motivate individuals to find solutions to the problem at hand.

Once individuals are aware there are flaws with the current flow and have been taken out of their old habits adapting a new policy, procedure or way of thinking is needed. As beneficial and pleasing as it would be for this to occur quickly unfortunately this is not always the case. It is important to make those involved with the adjustment feel as if they are a part of the dynamics of implementing change. In the scenario discussed this could include having Nurse J and the LPN help with a new conscious sedation policy. Having frontline staff be part of the variation can lead to peer acceptance and make those involved feel as if they are connected to the organization. As stated before, this is a process that may take time and will require energy.

Additional training and inservice may be needed. Again, having those involved initiating change can make implementation easier. Communication and involvement is key. Once change has occurred it is vitally important to make the alteration solid. This will keep an organization from revisiting the past and having to start the process all over. In the scenario it could be implementation of a conscious sedation policy as a unit ensuring it is followed on each and every conscious sedation procedure without deviation. The Emergency Department could also preform audits to verify there are no setbacks and even offer a reward system or recognition for those who have adopted change. C. Failure Mode and Effects Analysis

“Failure Mode and Effects Analysis (FMEA) is a structured way to identify and address potential problems, or failures and their resulting effects on the system or process before an adverse event occurs. In comparison, root cause analysis (RCA) is a structured way to address problems after they occur. FMEA involves identifying and eliminating process failures for the purpose of preventing an undesirable event” (Guidancefor FMEA.pdf, 2015). To prepare for a FMEA there needs to be several individuals in place for the process to become advantageous. The first being an advisor, or an individual well versed in the FMEA process. The second would be a leadership team. Third would be to choose a process followed by forming a multidisciplinary team. Failure mode and effects analysis needs to be made of a diverse team of individuals that can offer different unbiased perspectives.

In Mr. B’s scenario, team selection could potentially be a composed of the following: Emergency Department staff nurse, Emergency Department staff LPN, Emergency Department physician, Emergency Department secretary, staff respiratory therapist, and individual from hospital management. These individuals need to be made aware of the study at hand, in our case it would be the conscious sedation protocol. There needs to be a review of the current situation so all involved know what the analysis involves. A good way to keep this step in the process organized is by using flow charts describing each part of the process. For our scenario it could be a flow chart of the current conscious sedation policy.

It is important that everyone on the team is in agreement at this point in the FMEA process to avoid confusion or conflict during the analysis. Once all are up to date on the situation, looking at the current situation and finding potential areas of failure need to be addressed. This step needs to be thoroughly thought through leaving nothing out. Even if an individual thinks “it probably won’t happen” it should be included. With each of the areas of failure the team needs to determine potential outcomes. For example in our scenario “What would happen if a patient did not have continuos one on one care” The potential outcomes could be placed on numeric scale ranking from catastrophic to near miss. In this situation, the outcome could have a severity ranking of catastrophic. Rankings can also have other descriptors such as low, moderate severe and fatal. These terms can “be just as effective (and perhaps less intimidating)” (Guidancefor FMEA.pdf, 2015). Once the team has rated the events severity they move on to determine how often the failure is likely to occur.

This is can also be done on a raking scale of five to one. This ranking ranges from five being very high and one being unlikely. Once failures have been detected and ranked the next step is implementing changes to keep failures from occurring again. During this step “The Five Whys technique is a good way to drill-down to find the root cause of failures. The answer to the first “why” prompts another “why” and the answer to the second “why” prompts another and so on; hence the name the Five Whys” (Guidancefor FMEA.pdf, 2015).

For our scenario the first question could be “Why did the patient not have one on one care during conscious sedation” which would have and answer and be followed by the remaining “why” questions. This leads the team to a solution to the failures and aids in the implementation of actions that can keep the event from occurring again. These actions can be strong, intermediate and weak. An example of an intermediate action in our case would be to call back-up staff when patient volume increased. With any process it is vitally important to measure the effectiveness of the plan at hand. Sometimes, plans work without a problem other times actions may need to be re-evaluated and changed to accommodate the scenario at hand. Also, this plan needs to have a time frame for completion. Without the structure and evaluation the process will be less effective. D. Nursing in improving quality of care.

Nursing is an ever changing field. Changes can seen on a daily basis wether it be a changing patient population, change in protocol or treatments and even a personal change on how one feels and what emotion their profession brings to their life. “Nursing leaders can partner with other health care system leaders to create a culture that views challenges in care delivery as opportunities for team-based interprofessional systematic improvements. Not only will a greater understanding of these competencies prepare nurses to deliver the kind of care they desire for their patients, but the knowledge, skills, and attitudes embodied within these competencies can help increase their joy in work and prepare them for the rapidly changing landscape of regulatory quality” (Hall, Moore, & Barnsteiner, 2008).

In our scenario, catastrophic events could have potentially avoided if there was a minute to minute conscious effort to improve the quality of care. To begin there needs to be a culture among healthcare providers that promotes an open door of communication without the fear of resentment or backlash. Effective communication can deter events from occurring and build working relationships. Nurses are the link between physicians and patients and the communication line must not be broken. Nurses need to be effective with their critical thinking skills and utilize the resources at hand. Using base knowledge to prevent catastrophic events from occurring, such as the potentiation effect of medication. Knowing ,when we as nurses, have met our ability to perform effectively and need assistance is not only important for our well being but the well being of the patient and the organization as a whole. Integrating teamwork in the patient care effort not only builds a solid foundation for the organization but also for the positive outcome of the patient being treated.

If for some unfortunate reason an adverse event does occur nurses must remember they “provide valuable insights into care processes when working with patient safety leaders as part of a root cause analysis team. Nurses’ unique knowledge of the care provided is essential for designing the best improvements in care processes” (Hall, Moore, & Barnsteiner, 2008). Probably among the most import ways a nurse can improve quality of care is his/her own self care. This can be done in many ways. Meditation for stress reduction, continuing education for confidence in patient care, are just a few examples. Having a rested, positive, confident attitude when preparing and performing patient care can make difference and help her do no harm and give the utmost quality of care to each patient she/he comes in contact with.


Retrieved March 2, 2015, from currentnursing.com/nursing_theory/change_theory.html Retrieved March 2, 2015, from http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/GuidanceForFMEA.pdf Hall., Moore., & Barnsteiner. (2008). Medscape: Medscape Access. Retrieved from http://www.medscape.com/viewarticle/586737_3 Sentinel Event | Joint Commission. (n.d.). Retrieved from http://www.jointcommission.org/sentinel_event.aspx

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