Root Cause Analysis

Running Head: Organizational Systems and Quality Leadership

Organizational Systems and Quality Leadership
RTT- Task 2
Tara McColeman
Student ID:000297596
Student Mentor: Kristine Warner

1

Organizational Systems

2

This report is apart of a collaborative investigation that included interdisciplinary team members: Risk Management, ED physician, Anesthesiologist, Director of Nurses, respiratory therapist, and ED Nurse Manager. The purpose of this investigation is to determine the root cause analysis (RCA) of the sentinel event, which occurred in the emergency room. Once the cause is identified, a plan of action will be established, and a failure mode and effects analysis
(FMEA) will be done to reduce the likelihood that the new processes
Data Collection:
The team will gather and evaluate all internal and external data, scope of practice and clinical practice guidelines as outlined by the Board of Registered Nursing. All current hospital policies and procedures as it relates to conscious sedation.

Observation and Testing of conscious sedation modules:
Conscious sedation protocols will be tested on a quarterly basis, which will include a skills test of medication administration, onset and duration of medication, assessment and evaluation using the Aldrete scoring protocol. A score of 99% pass will be required, if unable to meet this scoring guideline, then further education at the time is required.

Failure Modes and Effects analysis (FMEA)
Is a systematic three-step knowledge process based on the Department of Defense Patient
Safety Center (2004). These processes are: Severity, Occurrence and Detection.

The formula is The Risk Priority Number, or RPN, is a numeric assessment of risk assigned to a process, or steps in a process, as part of Failure Modes and Effects Analysis (FMEA). The team assigns each failure mode a numerical value from 1 to
(Institute for Healthcare Improvement 2004.)

Goals
The goal of this process is to decrease the RPN for a given high-risk process by 50 percent within 1 year.

Conclusion:
Registered Nurses have the greatest impact on patient care, they are the largest employees in the hospital, and they are usually the first person the patient interacts with and last one prior to discharge home. Nursing has changed over the past decade and has become a task-oriented profession. It would be a beneficial to each and every nurse to take professional assertive training, when orders don 't seem appropriate and voice their concerns when they feel an order is inappropriate and not be imitated or concerned if they are written up for questioning an order.
The more knowledge and further education that each and every nurse can do will empower them to provide the best care possible and maintain professional dignity.

References
Institute for Healthcare Improvement (2004.) Risk Priority Number (from failure modes and effects analysis.)
Retrieved from Institute for Healthcare Improvement:
http://www.ihi.org/resources/Pages/Measures/RiskPriorityNumberfromFailureModesand