Root Modes And Effect Analysis: The Root Cause Analysis (RCA) Model

Introduction

The paper aims at utilizing the Root Cause Analysis (RCA) model to investigate the reasons that lead to his unfortunate sentinel situation faced by Mr. B. In doing so, the paper will sufficiently examine all the events that caused the incident. In accomplishing these objectives, the change theory will be used as the framework for developing an improvement plan that would help in preventing the reoccurrence of such incidence. The Failure Modes and Effects Analysis (FMEA) will be utilized in ensuring the success of the improvement plan. Most importantly, an evaluation of the fundamental roles of nurses towards ensuring the provision of quality of patient care such as in Mr. B’s scenario will be done.

Root Cause Analysis

Root cause

This will include finding out all the information regarding the case. Such could include recollecting the vital signs demonstrated by Mr. B during his hospitalization. Additionally, this will also include the documentation of pointing laboratory results such as elevated cholesterol and lipids levels, as well as the drugs he used.

Upon finishing the above, the team will need to establish the exact facts that caused the unfortunate incident to manifest. In this context, an inquest on the causative factors of his death will need to be determined. A good example is the fact that no one cared to consider the possibility of him being tolerant to opiates due to his age, as well as his renal condition. This certainly points to the fact that the hospital staff has inadequate knowledge on opiates. Additionally, the undertaking will also include an assessment on the information gathered and recorded about the patient. From the evidence in the case, it is obvious that Mr. B death resulted from medical error. Indeed, the team affirms this deduction as they conclude that the hydromorphone given to him was

Pre-Steps

Selection of a simpler process such as monitoring of hydromorphone for Mr. B’s case

Gathering the FMEA team members together to stipulate on the new hydromorphone monitoring process.

C3. Three Steps

Severity point indicates the possibility of harmful consequences such as in the case of giving the wrong hydromorphone dose, and failure to monitor ECG and respirations.

Detection point indicates the possibility of detecting what is wrong before it manifest such as, what went wrong in Mr. B’s situation would be detected.

Occurrence point indicates that in the possible repeat of the same mistake, similar outcomes would be seen meaning that wrong dosage and inaccurate ECG and respiration monitoring would have same results.

C4. Interventions

Formation of a program emphasizing on hydromorphone administration

Establishing a standard pain assessment and reassessment procedure

Mandatory training of all the staff on management of high thresholds pains

Establishing a clearly stipulated standard hydromorphone order set

Testing the Interventions

Conduct a standard test every three months within the emergency room, which should be accompanied by an evaluation of all the medical records for hydromorphone