Routine Case Analysis and Failure Mode and Effects Analysis
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Root cause analysis and Failure Mode and effects analysis are essential in determining an occurrence of critical events and curbing the occurrence of their advance effects (Shaqdan et al., 2014). By observing the two protocols, the healthcare facilities are in a position of not only providing quality care but also making sure all the patients receive safe care. This article dwells on a scenario of Mr. B who receive underwent admission and drug administration that made his management complicated and required an application of root cause analysis and a failure mode and effects analysis.
Root cause analysis (RCA)
Root cause analysis is a systematic way of determining the origin of problem or events and the manner of going about them. Its main purpose is to determine the matter at hand, how it happened, the reason for the occurrence and development of actions that will lead to the occurrence of such events (Latino, Latino & Latino, 2016)…
The next step is the development of problem statements. The statement links the causes and the effects which then related to the event itself. The causal statements recognize the cause and illustrate the manner unto which the contributing factors led to the undesirable event. The fifth step entails the generation of the list of the possible action that would prevent any recurrence of the situation (Latino, Latino & Latino, 2016)…
Process improvement plan and application of Lewin’s theory of change
To curb the reoccurrence of the medication error and its outcome the facility ought to embrace various moves that would not only ascertain patient safety but also ensure that the care provided is of quality…
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Failure mode and effects analysis (FMEA) process
This refers to a proactive and systematic manner of assessing a process to determine the point and way through which it may fail and even evaluate the impact of the anticipated failure…
FMEA Table
| Steps in the improvement Plan Process | Failure Mode | Likelihood of Occurrence
(1-10) |
Likelihood of Detection
(1-10) |
Severity
(1-10) |
Risk Priority Number
(RPN) |
| Doctor prescribing sedative drug for sedation during surgical procedure. | Wrong medication selected | 3 | 6 | 6 | 108 |
| Doctor prescribing drugs to the patient. | Wrong dosage | 2 | 5 | 5 | 50 |
| Assessment of patient eligibility | Not assessing the health status of patient | 5 | 4 | 6 | 120 |
| Use of history to determine intervention | Not taking thorough medical history of patient | 6 | 8 | 6 | 288 |
| 566 |
Testing the interventions from the process improvement plan to improve care
The interventions would be subjected to failure mode and effect analysis to determine any factors that can thwart their usage…
Demonstration of leadership by a professional nurse
A professional nurse needs always need to use evidence-based practice to carry out various nursing processes. At the same time, the nurse also leads and helps other nurses in maintaining protocols and guideline pertaining to various care actions…
Conclusion
The healthcare system experiences various shortcomings which impair both the quality and safety of care that patients receive…
References
Burke, W. W. (2017). Organization change: Theory and practice. Sage Publications.
Latino, R. J., Latino, K. C., & Latino, M. A. (2016). Root cause analysis: improving performance for bottom-line results. CRC press.
Makary, M. A., & Daniel, M. (2016). Medical error-the third leading cause of death in the US. BMJ: British Medical Journal (Online), 353.
Shaqdan, K., Aran, S., Besheli, L. D., & Abujudeh, H. (2014). Root-cause analysis and health failure mode and effect analysis: two leading techniques in health care quality assessment. Journal of the American College of Radiology, 11(6), 572-579.
