WGU C489 SAT TASK 2 RCA and FMEA Assignment

FMEA Table for Your Improvement Plan* WGU C489 SAT TASK 2 RCA and FMEA Assignment

List 4 steps in your Improvement Plan Process *	List 1 Failure Mode per step	Likelihood of Occurrence (1–10)	Likelihood of Detection (1–10)	Severity (1–10)	Risk Priority Number (RPN)
Example:  On-call staff must clock in within 30 minutes of being notified.	On-call staff forget to clock in when arriving to the unit.	4	5	2	40
1.
2.
3.
4.
	WGU C489 SAT TASK 2 RCA and FMEA Assignment				Total RPN (sum of all RPN’s):

FMEA Table for Your Improvement Plan* WGU C489 SAT TASK 2 RCA and FMEA Assignment

* Refer back to your Improvement Plan response in prompt B.

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. WGU C489 SAT TASK 2 RCA and FMEA Assignment

INTRODUCTION – WGU C489 SAT TASK 2 RCA and FMEA Assignment

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. WGU C489 SAT TASK 2 RCA and FMEA Assignment

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 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 a s needed. At the time of Mr. B’s arrival, WGU C489 SAT TASK 2 RCA and FMEA Assignment

WGU Performance Assessment 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. WGU C489 SAT TASK 2 RCA and FMEA Assignment

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. WGU C489 SAT TASK 2 RCA and FMEA Assignment

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 briefly, 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. WGU C489 SAT TASK 2 RCA and FMEA Assignment

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 fibrillation. CPR begins immediately by the RN, and Mr. B is intubated. He is defibrillated and reversal agents, IV fluids, 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 fixed 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.WGU C489 SAT TASK 2 RCA and FMEA Assignment

WGU Performance Assessment 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 specific discharge criteria (i.e., fully awake, VSS, no N/V, and able to void). All practitioners who perform moderate sedation must first 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 certification 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. Sufficient equipment was available and in working order in the ED on this day. WGU C489 SAT TASK 2 RCA and FMEA Assignment

WGU C489 SAT TASK 2 RCA and FMEA Assignment 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.WGU C489 SAT TASK 2 RCA and FMEA Assignment

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 defined 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 defined 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. WGU C489 SAT TASK 2 RCA and FMEA Assignment

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 • influencing quality improvement activities 1. Discuss how the involvement of the professional nurse in the RCA and FMEA processes demonstrates leadership qualities. https://tasks.wgu.edu/student/000903425/course/10460005/task/1235/overview 3/7 6/23/2019 WGU Performance Assessment 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. WGU C489 SAT TASK 2 RCA and FMEA Assignment

RUBRIC A:ROOT CAUSE ANALYSIS NOT EVIDENT COMPETENT – WGU C489 SAT TASK 2 RCA and FMEA Assignment

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 identifies 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 defined by IHI.

The explanation accurately RCA, as defined 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. WGU C489 SAT TASK 2 RCA and FMEA Assignment

B:IMPROVEMENT PLAN NOT EVIDENT APPROACHING COMPETENCE https://tasks.wgu.edu/student/000903425/course/10460005/task/1235/overview COMPETENT 4/7 6/23/2019 WGU Performance Assessment 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. WGU C489 SAT TASK 2 RCA and FMEA Assignment

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 defines each of the steps of the the FMEA process does not FMEA process. The description accurately accurately define each of the steps. WGU C489 SAT TASK 2 RCA and FMEA Assignment

C2:FMEA TABLE NOT EVIDENT A completed FMEA table is not APPROACHING COMPETENCE provided. https://tasks.wgu.edu/student/000903425/course/10460005/task/1235/overview COMPETENT The completed FMEA table appropriately identifies failure 5/7 6/23/2019 WGU Performance Assessment 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 identified failure modes. detection in evaluating the identified failure modes. WGU C489 SAT TASK 2 RCA and FMEA Assignment

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. WGU C489 SAT TASK 2 RCA and FMEA Assignment

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. WGU C489 SAT TASK 2 RCA and FMEA Assignment

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 identifies 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 difficult 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 reflects attention to meaning. Mechanics, usage, and grammar promote accurate interpretation and understanding. WGU C489 SAT TASK 2 RCA and FMEA Assignment

WEB LINKS IHI FMEA Tool SUPPORTING DOCUMENTS FMEA – WGU C489 SAT TASK 2 RCA and FMEA Assignment

Table.docx https://tasks.wgu.edu/student 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. WGU C489 SAT TASK 2 RCA and FMEA Assignment

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 … WGU C489 SAT TASK 2 RCA and FMEA Assignment