Organizational Systems & Quality Leadership
Root cause analysis (RCA)
Root cause analysis refers to a method meant to determine the conditions that lead to an individual to experience feelings of emotional exhaustion, low feelings of accomplishment and depersonalization (Reason, 1997). Emotional exhaustion can be defined as the feeling of dullness that is experienced by an individual. Depersonalization refers to the altitude by a nurse to develop an uncaring altitude towards a patient and this result to a nurse developing a feeling of not being competent and less satisfied with the job (Reason, 1997). There are risk factors that are associated with the nursing profession, for instance, when nurses come across deaths, conflict among staff, limited resources, and inadequate staff and short of training skills (Tounsel & Reising, 2005). In the case of the patient B, nurse J experienced a lot of hard time in trying to save the patient’s life despite her level of qualification. Health care organizations use the root cause analysis tools in order to provide training for the facilitators. In addition to the training the facilitators of health care, the industry extends its training past the hospital walls to other ancillary facilities for health care. According to Tounsel & Reising (2005) “root cause analysis does not only include acute care hospitals, but rehabilitation facilities, long-term care facilities, outpatient surgery centers, ambulatory services, and general office practices”. Root cause analysis is therefore focused to achieve positive health care solutions in a simple way. The scenario presented could have been simple if the patient’s attention was focused without delays.
During the process of health care, accidents that occur are attributed to specific levels of failure. Basically, there are four levels of failure in health care: unsafe supervision, organizational influences, unsafe acts and the conditions that occur before the unsafe acts. These failures result from individual weaknesses and barriers that hinder individuals from taking action. When many individual failures accumulate in an organization, the whole system is likely to fail. The scenario of Mr. B was associated with such failures as the administration of wrong drugs by the nurse J. In addition to these failures, the ED physician had evaluated Mr. B as having elevated cholesterol and lipids while the admitting nurse admitted Mr. B. of impaired glucose tolerance and prostate cancer. The medication that the ED physician were meant to suppress the back pain that Mr. B was experience and therefore they could not provide a good solution for the patient, thus led to his death.
The change theory uses organizational development in order to achieve the desired results. Organizational development uses planned and well organized efforts that are meant to improve the viability and effectiveness of the health care organizations. According to (Wendell & Bell (2003) “organizational development is a response to change, a complex educational strategy intended to change the beliefs, attitudes, values, and structure of organization so that they can better adapt to new technologies, marketing and challenges, and the dizzying rate of change itself”. Therefore organization development is meant to establish processes that are designed for the purposes of bringing specific results. In order to achieve such results, organization development can incorporate interventions by the use of behavioral-science knowledge, planning, system improvement, self analysis and organization reflection (Wendell & Bell, 2003). These interventions are expected to improve renewal processes and problem solving skills in an organization (Wendell & Cecil, 2003). This is achieved through a collaborative and an effective management organization. The current scenario of the rural hospital where Mr. B was admitted can be improved through organizational development. It is important for the management of the rural hospital to carry out an institutional assessment. This assessment is important in that it would assist in determining the kind of institutional change that is needed so as to improve the service delivery and reduce the chances of patients dying due to minor errors (Stranks, 2007). For instance, the hospital can train the nurses on how to handle patients during critical situations like that of Mr. B. In addition, the physician in the emergency department was not able to serve the three patients at one moment since there were some of the patients who required more attention, this can be improved by the addition of more health care staff.
Failure mode and effects analysis
FMEA is a procedure that is used to make an analysis of the possible failures in an organization. A well organized FMEA procedure can assist an organization to note the likely modes of failure based on the historical background when using similar services, this can help an organization to eliminate such failures from the system with less expenditure and efforts thereby cutting down the cost of service delivery (Cilliers, 1998). When using FMEA, failures that have serious consequences are given more priority. A FMEA is supposed to provide current actions and information of a risk so that they can be used for future improvement. This procedure is done during the designing of an improvement plan and this continues further during the operation stage. The outcomes of this analysis help an organization to design the remedial measures. This procedure can be employed by health care organizations so as to reduce or eliminate errors that arise in the process of health care provision. When an improvement plan like organizational development is implemented by a health care organization, it is important to subject it to a failure mode and effects analysis so as to determine if the are failures associated with such a plan (Cilliers, 1998). If such failures are detected at an early stage, they can easily be avoided or eliminated so as to attain the desired objectives. FMEA is therefore a process that should involve many stakeholders in the health care sector. For instance, physicians, RNs and any other support staff in the sector.
An error in medication for a patient can have varying effects to a patient; the error can either have fewer effects or can lead to permanent effects on the patient health or even death (Cilliers, 1998). The nurse therefore has a key role in determining the health of a patient; this is because the nurse delivers the medication to the patient and as well ensures that the patient gets the medication at an appropriate time. The RNs can either perform malpractices or have professional deficiencies that can lead to the death of a patient (Cilliers, 1998).
An intervention to improve health care services can be tested by comparison of the patient data and the prevalence of errors in services delivery. A new intervention is meant to introduce change in service delivery and there such a new idea should minimize the number of patients and the potential errors in service provision.
Pre-steps for preparing for the FMEA
Failure mode and effects analysis (FMEA) is first prepared before analyzing the effects of a medication (Langford, 1995). The preparation of this analysis involves first determining that the robustness and history of the effects are considered. Boundary diagrams and interface matrices are used to determine robustness analysis. Most of the failures in health care provision are as a result of individual or an organizational error. These kinds of errors are first determined since they can be controlled directly by the health professional. After these errors are identified their remedial measures should be described so as to determine the most desirable. The measures should then be entered in a table and then encoded so as identify the different elements (Langford, 1995).
Three steps of the FMEA
Severity: Is the first step and it is employed in determining the failure modes depending on the required functions and the expected effects. During this step, the extent of the failure of a medication is assessed by comparing its performance with the desired effects. Each failure mode should be determined during this step because the failure in one component of health care delivery can result to the failure of other components. Therefore there is need to consider the overall effects of one failure mode at this stage. Each effect should be given its own severity number from one (not dangerous) to 10 (dangerous). This numbering would help the health care professional to prioritize the failures.
Occurrence: Is the second step and for this case, what causes the failure mode is determined and the frequency of the failures is determined. The frequency of the cause of failure is also determined at this stage. This is done by considering similar services and the failure modes that are associated with such services or medications. All the likely factors that causes a failure mode should be determined at this stage and be recorded. For instance, the administration of a wrong drug to a patient can lead to health complications and therefore it is a failure mode. This failure mode should be identified and recorded as a percentage of the rate of the occurrence of this error (Langford, 1995).
Detection: This step is meant to determine the efficiency of the selected option. The health care professionals need to determine the best assessment method. A nurse is supposed to first determine the current medication that leads to failure and the one that is able to cure if it is administered to the patient. A medication performance is measured during this step so as to confirm whether it is of importance to the patient (Langford, 1995).
Role of the nurses
Nursing as a profession is governed by values and nursing codes. The major role of nurses is to examine all sorts of bioethical and ethical issues as specified by the nursing practice and theory. Nurses should emphasis the theoretical and practical measures when attending a patient. For the scenario of Mr. B, the nurse therefore had the role to examine the situation of the patient and judge what was needed to save his life. This included the determining the best medication for him and assisting him physically to administer the drugs.
The key role of the nurses is to report and respond to the medication errors. The RNs are supposed to assess a patient in order to check the presence of any medication error. In case of any medication the nurse is supposed to find the necessary documents and fill the forms before reporting to the physician who is in charge of a patient (Cilliers, 1998). In addition, the RN should conduct the root cause analysis of an error and make an assessment so as to critically determine how it occurred and therefore stop its consequences.
Langford, J. W., (1995). Logistics: Principles and Applications. New York: McGraw Hill.
Reason, J. T., (1990). Human Error. New York: Cambridge University Press.
Reason, J. T., (1997). Managing the Risks of Organizational accidents. New York: Cambridge University Press.
Stranks, J. (2007). Human Factors and Behavioral Safety. New York: Butterworth- Heinemann.
Tounsel, D. & Reising, D., (2005). Whether legislation can be helpful in reducing burnout among hospital nurses: A normative analysis. New York: McGraw Hill. Journal of Nursing Law, 10: (2), 89-95.
Wendell, L. & Cecil, B., (2003). Organization development: behavioral science interventions for organization improvement. Englewood Cliffs, N.J.: Prentice-Hall