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Root Cause Analysis for the Patient

Root Cause Analysis (RCA) identifies the root causes of events as well as problems experienced by an organization with an aim of seeking problem-solving skills (Stamatis, 2003). Thus, the root cause analysis is based on eliminating or correcting the main causes of a problem instead of addressing the problem by its apparent symptoms. In order to provide high-quality health care, the root cause analysis maintains that patients’ safety should be a fundamental element, and therefore all healthcare organizations and professionals should endeavor to provide safe health care services.

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Analysis of Errors/Hazards

There are a number of errors, which led Mr. B to pointless diagnoses. To start with, the health care workers portray ignorance on the part of reviewing the lab results of Mr. B. This ignorance emanates from the poor inter transfer process of lab results between Dr. T and nurse J, as nurse J had not informed Dr. T on the medical history of Mr. B; instead, Dr. T found out by himself; thus demonstrating error from decision roots (Latino, 2004). This led to an increase in the time under which proper medication should have been arrived at in the emergency department.

Though this health care facility is able to ascertain the level of pain for the patients, the nurses portray poor allocation of patients to their appropriate departments, as it allows patients who are not in a critical condition to accessing medical treatment from the emergency department, hence worsening the treatment of the patients who are eligible for emergency treatment. This is apparent in the case study where one patient suffering from a throbbing headache was already admitted to the emergency department, thus causing Mr. B’s treatment to delay. This demonstrates errors from the organization’s system roots (Latino, 2004).

The other major error that is present in this case study is that nurse J does not adhere to the legal nursing principle that calls for the definition of the physician’s role, the nursing role, back up staff roles, and the patient’s role, as this helps in preventing work overlap. The LPN who repeated the blood pressure monitoring process as it was going on demonstrates work overlap. The root cause of this error is that nurse J is not aware of the importance of adhering to the healthcare proposed guidelines even though he has successfully completed the moderate sedation-training program, thus demonstrating error from component or physical causes (Latino, 2004).

Improvement Plan

To come up with an efficient and effective improvement plan, it is imperative to have a description of how this improvement plan will be managed. Levasseur (2001) affirms that using a change theory known as the Lewin’s change model is imperative while developing an appropriate improvement plan since it upholds the process of change by following a clear sequence of steps, which include

  1. Unfreezing: this step calls for the need for change by providing substantial evidence through a proper analysis of the cause-effect relationship. In this case study, the unfreezing process should involve asking and answering a question that are relative to acquiring lab results and medical records of the patient efficiently and effectively, as well as how to improve patients’ care with regard to providing accurate medication.
  2. Change: the change process in this case study should be reflected by improvements in diverse areas including interpersonal communication between the medical practitioners on matters pertaining to the patients’ health reports, proper definition of each medical practitioner’s role, and acquisition of knowledge on the importance of nursing training programs;
  3. Refreezing: the refreezing stage of this improvement plan should focus on the awareness of the new changes as well as the challenges that may hinder the implementation of the changes. These challenges should form the basis for analysing how the improvement plan can be reinforced through a failure mode and effects analysis.

Failure Mode and Effects Analysis

According to Stamatis (2003) failure mode and effects analysis is a process that ensures efficiency and effectiveness of the change strategy intended to be adopted by an institution. This process normally analyzes the factors that would lead to failure of an improvement plan, the reasons for failure, as well as the consequences of failure. In this case study, FMEA is a powerful tool that can ensure that the improvement plan will not fail. This can be achieved by coming up with substantiated steps that facilitate change in the way diagnosis and medication procedures are handled as well as creating a balance that bridges the communication gap between various departments in this health care setting. Therefore, all the staff members of this hospital will be included in the RCA and FMEA since every procedure related to patient care is related to every staff member.

Through the FMEA, the health care facility should recognize the errors, which have a high probability of occurring before the implementation plan is put into place. One of the major errors that may occur in the emergency department is attributed to physicians’ limited knowledge on the essentials of the drugs they may want to prescribe to the patients. In such a case, the FMEA should ensure that the process does not fail by adding procedures that ensure the right medication is provided to the patient by including pharmacists on round (Stamatis, 2003). The presence of pharmacists on round is essential in this case study since the pharmacists could have assisted Dr. T in drug administration, and this, in turn, could have improved efficiency in the emergency department.

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The FMEA should also ensure that the implementation would not fail by putting a point across to nurse J that the moderate sedation training programs should not be practiced in order to fulfill the requirements Joint Commission of Accreditation of Healthcare organization [JCAHO], but to identify obstacles that contribute to the medical errors. Therefore, nurse J should be able to identify the goals that can be put in place in order to eliminate these medical errors. Some of these goals include improving the effectiveness of communication among caregivers in the hospital and improving the safety of diagnosis procedures in the hospitals.

Ways of Testing Intervention to Improve Care by Changing the Process of Care

The test of any intervention should be done against the already set target of the FMEA. This target helps to know whether errors emanating from human roots, decision root, as well component or physical roots have been restrained. In this case study, the intervention plan can be based on a set target: to reduce the number of human roots, decision roots, and component or physical root by 2%, 1.5%, and 1% respectively in a six months period.

More so, a checklist should also be used to verify whether there is an elimination of errors in this health care setting. This check list is of paramount importance since it will help in carrying out a cross comparison between the old and the new process of care, hence providing the health care workers with comprehensive information relative to the risks associated with the old process of care and the benefits associated with the new process of care obtained from the cost-benefit analysis.

Pre-steps for preparing for the FMEA

FMEA preparation calls for coming up with a criterion that helps in giving priority to areas that necessitate improvement (Stamatis, 2003). This can only be achieved by coming up with a number of steps including

  1. Subdividing departments according to area of expertise: effective implementation of FMEA can only be achieved if each area of expertise is handled independently.
  2. Recruiting the staff who should be involved in the FMEA analysis, and
  3. Mobilizing the entire team in order to come to come up with a consensus on the steps that should be involved in the FMEA analysis, which should then be demonstrated through flowcharts.

Three Steps of the FMEA

The three steps of FMEA are assigned a risk priority number [RPA] that weighs the failure mode of the improvement plan. These steps involve testing a number of prospects including

  1. Prospects of occurrence of failure: the validity of this test can be established through a 10 scale instrument that tries to establish the probability of an error occurring within the healthcare facility;
  2. Prospects of detection: the validity of this test can be established through a 10 scale instrument that tries to establish the probability of an error being detected before it deteriorates the health care delivery in a health care setting, and
  3. Severity: the validity of this test can be established through a 10 scale instrument that tries to establish the extent of the harm emanating from the errors (Stamatis, 2003).

The Key Role Nurses Would Play in Improving the Quality of Care in This Situation

Nurse practitioners can play a critical role in improving the quality of care in this situation on the short term as well as on the long-term basis. On the short-term basis, the nurse practitioners are supposed to take initiative in identification of the root causes by collecting information relative to treatment modalities of the health care institution in order to prevent reoccurrence of errors in the institution. On the long term, the nurses have a role of decreasing the chances of errors in the health care setting through a careful scrutiny of the failure mode effect analysis in order to prevent initial occurrence of an error even at times when the organization undergoes through a change process. However, these roles can only be achieved if the nurses bridge the communication gap between diverse departments within the health care settings.


Latino, R.J. (2004). Optimizing FMEA and RCA efforts in health care. Ashhr Journal, 24(3), 21-24.

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Levasseur, R. E. (2001). People Skills: Change Management Tools: Lewin’s Change Model. Interfaces, 31(4), 71-73.

Stamatis, D. H. (2003). Failure mode and effect analysis: FMEA from theory to execution. Milwaukee, Wisc: ASQC Quality Press.

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