Root Cause Analysis With Fema Report

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ROOT CAUSE ANALYSIS WITH FEMA REPORT Kaye Miller WGU Organizational Leadership and Quality Systems RTT1 July 05, 2015 ROOT CAUSE ANALYSIS WITH FEMA REPORT This report is to discuss the events in the ED at 3:30 p.m. that resulted in the expiration of Mr. B. The purpose of this meeting is to review interventions, policy & procedure, and systems in order to decrease the chances of the replication of events that lead to Mr. B’s unfortunate outcome. This committee will be implementing the Brainstorming method. Present are as listed: Nurse J CNO ED physician HR representative ED Clinical Manager Initially the ED was appropriately staffed with an RN, LPN, ED physician and secretary. The physician intended to perform a procedure…show more content…
The patient’s death was particularly difficult for the ER staff to digest as they viewed their actions as an attempt to expedite care with uncomplicated dismissal. It was decided that a Plan-Do-Study-Act approach would be the most effective process improvement plan. The staff was amenable in part due to the fact that the patient’s death affected them emotionally and many verbalized they wanted to do everything possible to ensure this did not happen again. Plan – Applicable policies in this scenario will be reviewed and updated. These policies contain staffing, chain of command, procedural, delegation of duties, Code Blue and Rapid Response, triage and Biomedical facets. Brief overview of the said policies discovered that some of the issues that contributed to this unfortunate outcome were, in fact, not addressed. Do – Changes in policy will distributed hospital-wide since some staff may be called upon to “float” to the…show more content…
The expectation is that awareness of policy changes will be immediate. FMEA, a systematic, proactive approach to detect possible failures for this implementation was used. A scale of 1-10 revealed the following: Severity Outcome = 2 (very low related to amenable staff) Occurrence Scale = 4 (failure possible but not probable due to education development of CBL) Detection Scale = 1 (related to time frame given) FMEA will consist of a multi-disciplinary team that includes an RT, RN, anesthesia representative, lay person (security or medical records personnel will suffice) and pharmacy. The existing policies were reviewed for clarity and verbiage. The committee came to the conclusions that the existing policies were not sufficient to address the circumstances that lead to Mr. B’s demise. The professional nurse will lead this team through the process. The nurse will ensure, via CNO, that the clinical managers of the nursing units as well as department heads of non-nursing units, address this process at weekly unit meetings. The nurse will be testing awareness of the process by performing a random sampling questionnaire one time in one month. The nurse will also increase awareness by speaking to the process in Shared Governance meetings. In these meeting it will also be discussed how the professional staff nurse can promote quality care and influence quality improvement activities.

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