Rtt1 Task 1 Analysis

6079 Words25 Pages
Running head: ORGANIZATIONAL SYSTEMS & QUALITY LEADERSHIP-RTT1-TASK 2 1 Organizational Systems & Quality Leadership RTT1 – Task 2 Sue Stallings Western Governors University Running head: ORGANIZATIONAL SYSTEMS & QUALITY LEADERSHIP-RTT1-TASK 2 2 Sentinel events are those events that are supposed to never occur, or never events. A sentinel event, as defined by The Joint Commission, is an unexpected occurrence involving death or serious physical or psychological injury, or “the risk thereof”. (Sentinel Event: Joint Commission). During the course of our scenario patient’s admission, treatment, and recovery, he suffered such an event. Multiple contributory events culminated to bring our patient, Mr. B, to an unanticipated and tragic…show more content…
Equally, each FMEA is updated with unforeseen failure modes; it becomes the model for the next design. It is critical to focus on one process as opposed to a large multi-step process. It is also important to focus on the clinical behaviors associated with the event such as following specific protocols, identifying and encouraging an environment where each person feels comfortable to have a questioning attitude, and to communicate effectively. The first phase of using the FMEA tool is to organize a team and assign responsibilities. . The team should consist of a variety of disciplines within the department and organization. The team could consist of the following participants:          Ed nurses and physician that was involved in the incident ED manager Respiratory therapy manager Respiratory therapist Pharmacist Organizational QM representation member Nurse champion Physician champion Nurse informaticist The team comes together to identify concerns in the process, to improve internal and external outcomes, focus on prevention, and to prioritize actions that should be taken to reduce risk. Included in the steps of formulating a FMEA is to identify failure modes that call out ways the process fails, identify what the impact of the failure is, what are direct causes of…show more content…
Pre-Steps The FMEA tool utilizes varied data to identify the steps needed for preventative recommendations. The steps are, Step 1: Identify a process within the event. The process should be small in overall scale. For instance, a process identified in the case of Mr. B is monitoring of sedated patients postprocedure, or the process of administering IV sedation. Attempting to address the large scale issue could potentially prevent the team’s progress is completing the FMEA. A large scale issue could also create missed opportunities for recommendations of preventing further similar events. Step 2: Gather a team. It is important to utilize a multidisciplinary team approach to allow for input form areas involved in the process that may not be readily known to everyone. Step 3: Ask the team to identify all the steps in the process being evaluated. Each step in the process should be numbered. For example #1 could be “patient admitted”. A method used at Sentara Healthcare incorporates the use of a large white board. Each team member is given a sticky pad to write their steps on, one step for each note. The team works together to place the notes on the white board in the correct sequence. This allows for the team to get a visualization of the complete process. Step 4: Identify failure modes. A failure mode is an outcome contributory to the event, anything that could go wrong. In the case of Mr. B an example of a failure mode is patient assessment. Once the failure modes are established

More about Rtt1 Task 1 Analysis

Open Document