C 489 Western Governors University Sat Task RCA and FMEA Discussion Healthcare organizations accredited by the Joint Commission are required to conduct a r

C 489 Western Governors University Sat Task RCA and FMEA Discussion Healthcare organizations accredited by the Joint Commission are required to conduct a root cause analysis

(RCA) in response to any sentinel event, such as the one described in the scenario attached below. Once the

cause is identified and a plan of action established, it is useful to conduct a failure mode and effects analysis

(FMEA) to reduce the likelihood that a process would fail. As a member of the healthcare team in the hospital

described in this scenario, you have been selected as a member of the team investigating the incident.

SCENARIO

It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient, arrives at the six-room emergency department

(ED) of a sixty-bed rural hospital. He has been brought to the hospital by his son and neighbor. At this time,

Mr. B is moaning and complaining of severe pain to his (L) leg and hip area. He states he lost his balance and

fell after tripping over his dog.

Mr. B was admitted to the triage room where his vital signs were B/P 120/80, HR-88 (regular), T-98.6, and R-

32, and his weight was recorded at 175 pounds. Mr. B. states that he has no known allergies and no previous

falls. He states, “My hip area and leg hurt really bad. I have never had anything like this before.” Patient rates

pain at 10 out of 10 on the numerical verbal pain scale. He appears to be in moderate distress. His (L) leg

appears shortened with swelling (edema in the calf), ecchymosis, and limited range of motion (ROM). Mr. B’s

leg is stabilized and then is further evaluated and discharged from triage to the emergency department (ED)

patient room. He is admitted by Nurse J. Nurse J finds that Mr. B has a history of impaired glucose tolerance

and prostate cancer. At Mr. B’s last visit with his primary care physician, laboratory data revealed elevated

cholesterol and lipids. Mr. B’s current medications are atorvastatin and oxycodone for chronic back pain.

After Mr. B’s assessment is completed, Nurse J informs Dr. T, the ED physician, of admission findings, and Dr.

T proceeds to examine Mr. B.

Staffing on this day consists of two nurses (one RN and one LPN), one secretary, and one emergency

department physician. Respiratory therapy is in-house and available as needed. At the time of Mr. B’s arrival,

6Ø23Ø2019†WGU†Performance†Assessment

https?ØØtasksÆwguÆeduØstudentØ000903425ØcourseØ10460005ØtaskØ1235Øoverview†2Ø7

the ED staff is caring for two other patients. One patient is a 43-year-old female complaining of a throbbing

headache. The patient rates current pain at 4 out of 10 on numerical verbal pain scale. The patient states that

she has a history of migraines. She received treatment, remains stable, and discharge is pending. The second

patient is an eight-year-old boy being evaluated for possible appendicitis. Laboratory results are pending for

this patient. Both of these patients were examined, evaluated, and cared for by Dr. T and are awaiting further

treatment or orders.

After evaluation of Mr. B, Dr. T writes the order for Nurse J to administer diazepam 5 mg IVP to Mr. B. The

medication diazepam is administered IVP at 4:05 p.m. After five minutes, the diazepam appears to have had

no effect on Mr. B, and Dr. T instructs Nurse J to administer hydromorphone 2 mg IVP. The medication

hydromorphone is administered IVP at 4:15 p.m. After five minutes, Dr. T is still not satisfied with the level of

sedation Mr. B has achieved and instructs Nurse J to administer another 2 mg of hydromorphone IVP and an

additional 5 mg of diazepam IVP. The physician’s goal is for the patient to achieve skeletal muscle relaxation

from the diazepam, which will aid in the manual manipulation, relocation, and alignment of Mr. B’s hip. The

hydromorphone IVP was administered to achieve pain control and sedation. After reviewing the patient’s

medical history, Dr. T notes that the patient’s weight and current regular use of oxycodone appear to be

making it more difficult to sedate Mr. B.

Finally, at 4:25 p.m., the patient appears to be sedated, and the successful reduction of his (L) hip takes place.

The patient appears to have tolerated the procedure and remains sedated. He is not currently on any

supplemental oxygen. The procedure concludes at 4:30 p.m.,and Mr. B is resting without indications of

discomfort and distress. At this time, the ED receives an emergency dispatch call alerting the emergency

department that the emergency rescue unit paramedics are enroute with a 75-year-old patient in acute

respiratory distress. Nurse J places Mr. B on an automatic blood pressure machine programmed to monitor

his B/P every five minutes and a pulse oximeter. At this time, Nurse J leaves Mr. B’s room. The nurse allows

Mr. B’s son to sit with him as he is being monitored via the blood pressure monitor. At 4:35 p.m., Mr. B’s B/P is

110/62 and his O2 saturation is 92%. He remains without supplemental oxygen and his ECG and respirations

are not monitored.

**** PLEASE SEE ATTACHED*** INCLUDES REQUIRED PAPERS AND QUESTION **** 6/23/2019
WGU Performance Assessment
SAT1 — SAT TASK 2: RCA AND FMEA
ORGANIZATIONAL SYSTEMS AND QUALITY LEADERSHIP — C489
PERFORMANCE ASSESSMENT — SAT1
COMPETENCIES
734.3.1Principles of Leadership
The graduate applies principles of leadership to promote high-quality healthcare in a variety of settings
through the application of sound leadership principles.
734.3.2Interdisciplinary Collaboration
The graduate applies theoretical principles necessary for effective participation in an interdisciplinary team.
734.3.3Quality and Patient Safety
The graduate applies quality improvement processes intended to achieve optimal healthcare outcomes,
contributing to and supporting a culture of safety.
INTRODUCTION
Healthcare organizations accredited by the Joint Commission are required to conduct a root cause analysis
(RCA) in response to any sentinel event, such as the one described in the scenario attached below. Once the
cause is identi?ed and a plan of action established, it is useful to conduct a failure mode and effects analysis
(FMEA) to reduce the likelihood that a process would fail. As a member of the healthcare team in the hospital
described in this scenario, you have been selected as a member of the team investigating the incident.
SCENARIO
It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient, arrives at the six-room emergency department
(ED) of a sixty-bed rural hospital. He has been brought to the hospital by his son and neighbor. At this time,
Mr. B is moaning and complaining of severe pain to his (L) leg and hip area. He states he lost his balance and
fell after tripping over his dog.
Mr. B was admitted to the triage room where his vital signs were B/P 120/80, HR-88 (regular), T-98.6, and R32, and his weight was recorded at 175 pounds. Mr. B. states that he has no known allergies and no previous
falls. He states, “My hip area and leg hurt really bad. I have never had anything like this before.” Patient rates
pain at 10 out of 10 on the numerical verbal pain scale. He appears to be in moderate distress. His (L) leg
appears shortened with swelling (edema in the calf), ecchymosis, and limited range of motion (ROM). Mr. B’s
leg is stabilized and then is further evaluated and discharged from triage to the emergency department (ED)
patient room. He is admitted by Nurse J. Nurse J ?nds that Mr. B has a history of impaired glucose tolerance
and prostate cancer. At Mr. B’s last visit with his primary care physician, laboratory data revealed elevated
cholesterol and lipids. Mr. B’s current medications are atorvastatin and oxycodone for chronic back pain.
After Mr. B’s assessment is completed, Nurse J informs Dr. T, the ED physician, of admission ?ndings, and Dr.
T proceeds to examine Mr. B.
Staf?ng on this day consists of two nurses (one RN and one LPN), one secretary, and one emergency
department physician. Respiratory therapy is in-house and available as needed. At the time of Mr. B’s arrival,
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the ED staff is caring for two other patients. One patient is a 43-year-old female complaining of a throbbing
headache. The patient rates current pain at 4 out of 10 on numerical verbal pain scale. The patient states that
she has a history of migraines. She received treatment, remains stable, and discharge is pending. The second
patient is an eight-year-old boy being evaluated for possible appendicitis. Laboratory results are pending for
this patient. Both of these patients were examined, evaluated, and cared for by Dr. T and are awaiting further
treatment or orders.
After evaluation of Mr. B, Dr. T writes the order for Nurse J to administer diazepam 5 mg IVP to Mr. B. The
medication diazepam is administered IVP at 4:05 p.m. After ?ve minutes, the diazepam appears to have had
no effect on Mr. B, and Dr. T instructs Nurse J to administer hydromorphone 2 mg IVP. The medication
hydromorphone is administered IVP at 4:15 p.m. After ?ve minutes, Dr. T is still not satis?ed with the level of
sedation Mr. B has achieved and instructs Nurse J to administer another 2 mg of hydromorphone IVP and an
additional 5 mg of diazepam IVP. The physician’s goal is for the patient to achieve skeletal muscle relaxation
from the diazepam, which will aid in the manual manipulation, relocation, and alignment of Mr. B’s hip. The
hydromorphone IVP was administered to achieve pain control and sedation. After reviewing the patient’s
medical history, Dr. T notes that the patient’s weight and current regular use of oxycodone appear to be
making it more dif?cult to sedate Mr. B.
Finally, at 4:25 p.m., the patient appears to be sedated, and the successful reduction of his (L) hip takes place.
The patient appears to have tolerated the procedure and remains sedated. He is not currently on any
supplemental oxygen. The procedure concludes at 4:30 p.m.,and Mr. B is resting without indications of
discomfort and distress. At this time, the ED receives an emergency dispatch call alerting the emergency
department that the emergency rescue unit paramedics are enroute with a 75-year-old patient in acute
respiratory distress. Nurse J places Mr. B on an automatic blood pressure machine programmed to monitor
his B/P every ?ve minutes and a pulse oximeter. At this time, Nurse J leaves Mr. B’s room. The nurse allows
Mr. B’s son to sit with him as he is being monitored via the blood pressure monitor. At 4:35 p.m., Mr. B’s B/P is
110/62 and his O2 saturation is 92%. He remains without supplemental oxygen and his ECG and respirations
are not monitored.
Nurse J and the LPN on duty have received the emergency transport patient. They are also in the process of
discharging the other two patients. Meanwhile, the ED lobby has become congested with new incoming
patients. At this time, Mr. B’s O2 saturation alarm is heard and shows “low O2 saturation” (currently showing
a saturation of 85%). The LPN enters Mr. B’s room brie?y, resets the alarm, and repeats the B/P reading.
Nurse J is now fully engaged with the emergency care of the respiratory distress patient, which includes
assessments, evaluation, and the ordering of respiratory treatments, CXR, labs, etc.
At 4:43 p.m., Mr. B’s son comes out of the room and informs the nurse that the “monitor is alarming.” When
Nurse J enters the room, the blood pressure machine shows Mr. B’s B/P reading is 58/30 and the O2
saturation is 79%. The patient is not breathing and no palpable pulse can be detected.
A STAT CODE is called and the son is escorted to the waiting room. The code team arrives and begins
resuscitative efforts. When connected to the cardiac monitor, Mr. B is found to be in ventricular ?brillation.
CPR begins immediately by the RN, and Mr. B is intubated. He is de?brillated and reversal agents, IV ?uids,
and vasopressors are administered. After 30 minutes of interventions, the ECG returns to a normal sinus
rhythm with a pulse and a B/P of 110/70. The patient is not breathing on his own and is fully dependent on
the ventilator. The patient’s pupils are ?xed and dilated. He has no spontaneous movements and does not
respond to noxious stimuli. Air transport is called, and upon the family’s wishes, the patient is transferred to a
tertiary facility for advanced care.
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Seven days later, the receiving hospital informed the rural hospital that EEG’s had determined brain death in
Mr. B. The family had requested life-support be removed, and Mr. B subsequently died.
Additional information: The hospital where Mr. B. was originally seen and treated had a moderate
sedation/analgesia (“conscious sedation”) policy that requires that the patient remains on continuous B/P,
ECG, and pulse oximeter throughout the procedure and until the patient meets speci?c discharge criteria
(i.e., fully awake, VSS, no N/V, and able to void). All practitioners who perform moderate sedation must ?rst
successfully complete the hospital’s moderate sedation training module. The training module includes drug
selection as well as acceptable dose ranges. Additional (backup) staff was available on the day of the incident.
Nurse J had completed the moderate sedation module. Nurse J had current ACLS certi?cation and was an
experienced critical care nurse. Nurse J’s prior annual clinical evaluations by the manager demonstrated that
the nurse was “meeting requirements.” Nurse J did not have a history of negligent patient care. Suf?cient
equipment was available and in working order in the ED on this day.
REQUIREMENTS
Your submission must be your original work. No more than a combined total of 30% of the submission and no more
than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if
cited correctly. An originality report is provided when you submit your task that can be used as a guide.
You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be
used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric
aspect titles may contain hyperlinks to relevant portions of the course.
A. Explain the general purpose of conducting a root cause analysis (RCA).
1. Explain each of the six steps used to conduct an RCA, as de?ned by IHI.
2. Apply the RCA process to the scenario to describe the causative and contributing factors that led to
the sentinel event outcome.
B. Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario
outcome.
1. Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the
proposed improvement plan.
C. Explain the general purpose of the failure mode and effects analysis (FMEA) process.
1. Describe the steps of the FMEA process as de?ned by IHI.
2. Complete the attached FMEA table by appropriately applying the scales of severity, occurrence, and
detection to the process improvement plan proposed in part B.
Note: You are not expected to carry out the full FMEA.
D. Explain how you would test the interventions from the process improvement plan from part B to improve
care.
E. Explain how a professional nurse can competently demonstrate leadership in each of the following areas:
• promoting quality care
• improving patient outcomes
• in?uencing quality improvement activities
1. Discuss how the involvement of the professional nurse in the RCA and FMEA processes demonstrates
leadership qualities.
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F. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or
summarized.
G. Demonstrate professional communication in the content and presentation of your submission.
RUBRIC
A:ROOT CAUSE ANALYSIS
NOT EVIDENT
COMPETENT
An explanation of the general
APPROACHING
COMPETENCE
purpose of conducting an RCA is
The explanation does not
describes the general purpose
not provided.
accurately describe the general
for conducting an RCA.
The explanation accurately
purpose for conducting an RCA.
A1:RCA STEPS
NOT EVIDENT
COMPETENT
An explanation of 6 RCA steps is
APPROACHING
COMPETENCE
not provided.
The explanation does not
identi?es and logically
accurately identify or does not
describes each of the 6 steps
logically describe one or more of
used to conduct an RCA, as
the 6 steps used to conduct an
de?ned by IHI.
The explanation accurately
RCA, as de?ned by IHI.
A2:CAUSATIVE AND CONTRIBUTING FACTORS
NOT EVIDENT
COMPETENT
An application of the RCA
APPROACHING
COMPETENCE
process to the scenario is not
The application of the RCA
process to the scenario
provided.
process to the scenario does not
accurately describes the
accurately describe causative or
causative and contributing
contributing factors that led to
factors that led to the sentinel
the sentinel event outcome, or
event outcome.
The application of the RCA
the application does not
accurately differentiate
between causative and
contributing factors.
B:IMPROVEMENT PLAN
NOT EVIDENT
APPROACHING
COMPETENCE
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A proposed process
The proposal does not outline a
The proposal outlines a logical
improvement plan is not
logical process improvement
process improvement plan and
provided.
plan, or the proposal does not
logically discusses how the
logically discuss how the
proposed plan will decrease the
proposed plan will decrease the
likelihood of a reoccurrence of
likelihood of a reoccurrence of
the scenario outcome.
the scenario outcome.
B1:CHANGE THEORY
NOT EVIDENT
COMPETENT
A discussion of the application
APPROACHING
COMPETENCE
of Lewin’s change theory is not
The discussion does not logically
how each phase of Lewin’s
provided.
describe how Lewin’s change
change theory could be applied
theory could be applied to the
to the proposed improvement
proposed improvement plan, or
plan.
The discussion logically describes
the discussion does not
describe each phase of the
theory.
C:GENERAL PURPOSE OF FMEA
NOT EVIDENT
COMPETENT
An explanation of the general
APPROACHING
COMPETENCE
purpose of the FMEA process is
The explanation does not
describes a general purpose of
not provided.
accurately describe a general
the FMEA process and logically
purpose of the FMEA process,
discusses why the FMEA process
or the explanation does not
would be used.
The explanation accurately
logically discuss why the FMEA
process would be used.
C1:STEPS OF FMEA PROCESS
NOT EVIDENT
COMPETENT
A description of the steps is not
APPROACHING
COMPETENCE
provided.
The description of the steps of
de?nes each of the steps of the
the FMEA process does not
FMEA process.
The description accurately
accurately de?ne each of the
steps.
C2:FMEA TABLE
NOT EVIDENT
A completed FMEA table is not
APPROACHING
COMPETENCE
provided.
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COMPETENT
The completed FMEA table
appropriately identi?es failure
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The FMEA table is incomplete,
modes related to the
does not identify appropriate
improvement plan proposed in
failure modes related to the
part B and demonstrates
improvement plan proposed in
accurate application of the scales
prompt B, or does not
of severity, occurrence, and
accurately apply the scales of
detection in evaluating the
severity, occurrence, and
identi?ed failure modes.
detection in evaluating the
identi?ed failure modes.
D:INTERVENTION TESTING
NOT EVIDENT
COMPETENT
An explanation of intervention
APPROACHING
COMPETENCE
testing is not provided.
The explanation does not
of the testing procedures or
describe steps of an appropriate
practices that the candidate
testing procedure or practice
would use that are appropriate
that would be used by the
for testing the interventions
candidate to test interventions
from the process improvement
from the process improvement
plan in part B. The explanation
plan in part B, or the explanation
logically describes how the
does not logically describe how
intervention testing procedures
the intervention testing
or practices would improve care.
The explanation describes steps
procedures or practices would
improve care.
E:DEMONSTRATE LEADERSHIP
NOT EVIDENT
COMPETENT
An explanation of how a
APPROACHING
COMPETENCE
professional nurse
The explanation does not
describes how a professional
demonstrates leadership is not
logically describe how a
nurse competently demonstrates
provided.
professional nurse competently
leadership in each of the given
demonstrates leadership in one
areas.
The explanation logically
or more of the given areas.
E1:INVOLVING PROFESSIONAL NURSE IN RCA AND FMEA PROCESSES
NOT EVIDENT
COMPETENT
A discussion of involvement in
APPROACHING
COMPETENCE
the RCA and FMEA processes is
The discussion does not logically
how the involvement of the
not provided.
describe how the involvement of
professional nurse in both the
the professional nurse
RCA and FMEA processes
in either the RCA process or the
demonstrates leadership
The discussion logically describes
qualities.
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FMEA process demonstrates
leadership qualities.
F:SOURCES
NOT EVIDENT
COMPETENT
The submission does not include
APPROACHING
COMPETENCE
both in-text citations and a
The submission includes in-text
citations for sources that are
reference list for sources that
citations for sources that are
properly quoted, paraphrased, or
are quoted, paraphrased, or
quoted, paraphrased, or
summarized and a reference list
summarized.
summarized and a reference list;
that accurately identi?es the
however, the citations or
author, date, title, and source
reference list is incomplete or
location as available.
The submission includes in-text
inaccurate.
G:PROFESSIONAL COMMUNICATION
NOT EVIDENT
COMPETENT
Content is unstructured, is
APPROACHING
COMPETENCE
disjointed, or contains pervasive
Content is poorly organized, is
detail, is organized, and focuses
errors in mechanics, usage, or
dif?cult to follow, or contains
on the main ideas as prescribed
grammar. Vocabulary or tone is
errors in mechanics, usage, or
in the task or chosen by the
unprofessional or distracts from
grammar that cause confusion.
candidate. Terminology is
the topic.
Terminology is misused or
pertinent, is used correctly, and
ineffective.
effectively conveys the intended
Content re?ects attention to
meaning. Mechanics, usage, and
grammar promote accurate
interpretation and
understanding.
WEB LINKS
IHI FMEA Tool
SUPPORTING DOCUMENTS
FMEA Table.docx
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Patient Safety 104: Root Cause and Systems Analysis
Summary Sheet
Lesson 1: Root Cause Analysis Helps Us Learn from Errors
?
?
?
?
A root cause analysis (RCA) is a systematic approach to understanding the causes of an adverse
event and identifying system flaws that can be corrected to prevent the error from happening
again.
o By definition, RCAs are retrospective: they look back at an error that occurred.
o An RCA is not appropriate in cases of negligence or willful harm.
Laying events out in chronological order is one way to understand the past, but when we start
to group events into categories, we begin to see them in a different way.
Focusing on system causes, rather than blame, is the central feature of root cause analysis.
o A systems approach to error asks, “What circumstances led a reasonable person to
make reasonable decisions that resulted in an undesirable outcome?”
Accidents in health care almost never stem from a single, linear cause. They come from a mix
of active failures, work conditions, and deeply embedded latent failures – what some safety
experts call contributory factors – that all align precisely to slip through every existing defense.
Lesson 2: How a Root Cause Analysis Works
?
?
Typically, an RCA team consists of four to six people from a mix of different professionals.
? The team should include individuals at all levels of the organization who are close to and
have fundamental knowledge of the issues and processes involved in the incident.
? Experts disagree on whether people involved in the event should be on the
team.
? Some RCA teams include patients and family members.
? It’s import…
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