Root-Cause Analysis and Safety Improvement Plan Root-cause analysis (RCA) is a systematic method used to identify the underlying causes of adverse events or near misses in healthcare settings, aiming to prevent their recurrence and enhance patient safety (Singh, 2023). In this paper, I will conduct a root-cause analysis and develop a safety improvement plan for the issue of delayed response to deteriorating patient condition in an acute care setting. This issue is particularly critical in acute care environments where timely intervention can mean the difference between life and death.This analysis is vital for understanding the factors contributing to delayed responses and implementing effective strategies to mitigate risks and enhance patient …show more content…
These factors create an environment where patients at risk of deterioration may not receive timely interventions, resulting in adverse outcomes such as prolonged hospital stays, increased morbidity, and mortality. In my role as a nurse on an acute care floor, I encountered a patient who experienced a deteriorating condition, prompting the need to call a rapid response team (RRT). The patient, an elderly individual admitted for treatment of pneumonia, began to exhibit signs of respiratory distress, including increased respiratory rate, labored breathing, and oxygen saturation levels dropping to 80%. Despite administering supplemental oxygen and positioning the patient appropriately, their condition continued to worsen rapidly. As the primary nurse responsible for their care, I promptly recognized the urgency of the situation and initiated the appropriate protocols to activate the RRT. However, upon reflection and analysis of the event, several factors contributing to the delayed response became apparent. On that particular day, I was assigned to care for six patients, which further compounded the challenges of providing timely and comprehensive care to each individual. Therefore, due to high patient acuity …show more content…
Application of Evidence-Based Strategies Implementing evidence-based interventions is crucial in effectively addressing these challenges. Early warning scoring systems (EWSS) empower nurses to promptly identify signs of deterioration, facilitating timely intervention to prevent the worsening of a patient's condition. An EWSS consists of both input and output components. The input entails identifying patients whose condition is deteriorating and triggering an appropriate response. The output encompasses the response itself, which may involve heightened monitoring, assessment by a rapid response team, or transfer to the intensive care unit (Nagarajah et al., 2022). Rapid response teams (RRT) have emerged as a simple yet effective approach to tackling the primary factors contributing to Failure to Rescue (FTR). This includes deficiencies in monitoring and identifying patients at high risk of rapid clinical decline,
My paper will talk about the communication in our department and company wide. The next topic my paper will talk about is culture that exists in our organization for safety in the workplace and home. Then we will move into a process that our company have which address conflict in the workplace. Finally, the technology enhancements that we have changed to improve our process, address customers concerns, and automation of some of our service we offer to our customers, which include our meter reading
A hospital is a difficult place to run because there so many aspects to manage. There are many types of doctors and nurses, and so many departments in this type of facility. The patients come in a wide variety of different ailments, needs, colors, sizes, personalities, and beliefs. Not to mention, with all of the equipment, devices, and people coming and going a hospital can seem like a small town in itself. That is why it will take a group effort, open communication, and positive reinforcement to
Critical Thinking Techniques Used In Root Cause Analysis Root cause analysis is a common term used by investigators and analysts that means different things to different people. However, in its most literal sense root cause analysis requires the performer to systematically break down a situation into individual components or processes in a search for truth that can be supported by facts (Eckhardt, 2007). This analysis should be conducted in the form of an investigation into both the apparent symptoms
of paper ... ...ts as much as possible. Any other quick remedies to prevent seat damage, caution labels, protective packaging/coating, etc. should be instigated in the short-term. In the long term, the costs associated with the increased delivery frequency, off-line corrective action, special packaging etc. would be prohibitive and a solution to the problem must be sought that can be monitored within the TPS. A design change to prevent damage to the seats will be found through the root cause
The case study analysis of Engstrom shows that they are currently experiencing organizational issues with employee’s dissatisfaction (lack of motivation), failed incentive plans (Scanlon Plan), and major issues with production and quality issues. When a corporation is experiencing these types of organizational issues such as Engstrom, the root causes of these issues need to be analyzed. A Root Cause Analysis is a five step process to answer the question of why the problem occurred in the first
TJC mandates the healthcare facility perform a root cause analysis (RCA) so they fully understand the why the event happened and can implement an action plan to prevent them from recurring (Cherry & Jacob, 2017). TJC will review the RCA and subsequent interventions taken by the facility to determine if they complied with national quality standards. In this reflection I will review some of most common root causes of sentinel events, pinpoint the root cause that I believe poses the greatest risk to patient
network and system administrators by e ectively ex- pressing the status of the environment we are dealing with, enabling network status analysis in static and real-time data, and making visual link graphs and tree maps any laymen is able to utilize. Good visualization can aid any number of critical measures such as capacity planning, forensics, and root cause analysis [22]. As mentioned in the PRADS section above, the output obtained from executing PRADS resides in a log le in texts with CSV format
A. Root Cause Analysis Root cause analysis (RCA) is a system-oriented and team-oriented approach to understanding errors and accidents to prevent reoccurrence. An RCA team works together to understand what happened, why it happened, how to prevent future adverse events, how system changes will improve safety. Commonly, used in healthcare, an RCA is only useful if results in a specific action that improves the safety of the system. Ideally, by using RCA, failures will be converted into learning opportunities
Power transformers are the most expensive and strategic components of electric power system [1]. It plays an important role by interconnecting in every stage of power transmission and distribution system [2]. The advantage of power transformers are mainly used for either step up or step down voltages according to the application requirement. The population of transformers in service is increasing because of the load growth, which is continuously subjected to electrical, mechanical, thermal and chemical
Introduction: The paper primarily focuses on the adapting Lean Thinking in a company. This paper gives a basic perspective of Lean application. The paper investigates and elucidates Lean by demonstrating how the procedure can be augmented to include incremental worth. The paper exhibits how Lean systems can be adjusted into certifiable circumstances by applying Lean instruments to the genuine organization. In this way, organizations of distinctive administration commercial ventures can likewise
A root cause analysis is a mechanism used to determine if procedures prompt sentinel occasions. A sentinel occasion is characterized by Cherry and Jacob as "a startling event that can cause genuine physical or psychologic damage or the danger thereof." (Cherry and Jacob, 2011, p. 444) The goal of a root cause analysis is to distinguish the components which brought on the sentinel occasion and to recognize imperfections in the framework which can be adjusted with a specific end goal to keep a rehash
called a Cause & Effect Diagram, or Ishikawa Diagram) is considered one of the 7 basic quality tools, and is often used as part of Lean-Kaizen workshops. A fishbone diagram that helps the assessing of the current state whilst assisting in getting to the root cause of a problem. This will help employees to identify solutions once a root cause is known. Fishbone diagram is also a good way to break a problem down in a structured way. “For every effect there is a root cause. Find and address the root cause
Fonte, P. Duarte, L. Reis, M. Freitas, V. Infante (2015) in this paper investigation is carried on two damaged crankshafts of single cylinder diesel engines used in agricultural services for several purposes. Recurrent damages of these crankshafts type have happened after approximately 100 h in service. The root cause never was imputed to the manufacturer. The fatigue design and an accurate prediction of fatigue life are of primordial importance
There are many different types of decision making processes that an organization can use to help resolve these problems. This paper will examine some of the different types of decision making processes with examples from four organizations. This includes the decision making processes strengths and weaknesses, as well as comparing and contrasting them with each other. This paper will also describe how a problem can best be identified and described to stakeholders in a manner that is sensitive to their
baseline performance of the process of the automotive manufacturing company, in order to identify the potential causes of the process related problem. They collected various types of data on all the identified potential causes and different types of statistical analysis like regression analysis, hypothesis testing and Taguchi methods were performed in order to identify the main causes. They used Beta correction technique to monitor the process in the control phase. And the results were observed.