Structure is measured by the staff: amount, skill-level, and education or certification. Process indicators measure the facets of nursing care, such as assessment and intervention. Outcome indicators refer to patient outcomes that are affected by nursing care and are considered nursing-sensitive if directly affected by the quantity or quality of the nursing care (ANA, 2013). Through understanding of nursing-sensitive indicators and integration into daily practice, the staff caring for Mr. J could have been more aware of potential issues that interfere with patient care. Knowledge of the increased risk for pressure ulcers and the need for frequent turning and off-loading of pressure points could have allowed the staff to prevent the one forming along Mr. J’s spine.
Mr. J was in restraints in this case. One of the quality indicators developed by the American Nurses Association is the prevalence of restraints (Cherry and Jacob 2011). It is important for nursing in this case to be aware of the potential outcomes for this patient in regards to restraint use. The staff in this situation can utilize nursing speciﬁc indicators to recognize the appropriate interventions that need to take place when a patient is placed in restraints. Recognizing at restraint use is a nursing speciﬁc indicator can help the staff in this situation develop an appropriate care plan.
Root Cause Analysis of a Case Study Alice Holliday Western Governors University Organizational Systems and Quality Leadership RTT1 Root Cause Analysis of a Case Study Healthcare presents numerous opportunities for patients to be helped by healthcare personnel. Unfortunately, there are also numerous opportunities for patients to be failed by healthcare personnel. When patients are failed by healthcare personnel, it is required by the Joint Commission for hospitals to carry out a Root Cause Analysis in order to understand the systems within the organization that failed so that improvements can be made and the failures can be prevented from happening in the future. (Cherry & Jacob, 2011) This paper will describe how a Root Cause Analysis (RCA) can be used following the death of a patient, and how Change Theory and Failure Mode and Effects Analysis (FMEA) can be utilized to come up with ways to prevent the failure from being repeated. A. Root Cause Analysis A Root Cause Analysis is an organized process used to determine the processes that lead to sentinel events.
Lastly, key roles nurses would play in improving the quality of care in the Mr. B scenario will be discussed.A. Root Cause AnalysisA root cause analysis (RCA) is “a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event” (Cherry & Jacob, 2011, p. 442). The participants during the root cause analysis would be the emergency room physician (Dr. T.), the Mr. B’s LPN and RN (Nurse J) during the time of the sentinel event, the emergency room nurse manager, and the chief nursing officer (CNO) of the hospital. These members would meet in a root cause analysis meeting to discuss the causative factors that created Mr. B’s sentinel event. The first step in a root cause analysis on the sentinel event that caused Mr. B’s death is to gather the data surrounding the situation.
I will outline a prevention plan and discuss how to stay compliant. I will discuss the changes that are necessary to stay compliant. I will explain the growth in leadership in the HIM department that will mentor compliance behavior as to mitigate legal risk. I will develop a simple plan, with proper detail to teach the clinical staff ways to improve clinical documentation. Compliance
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Change theory will be utilized to implement the plan. A failure mode and effects analysis (FMEA) will project the likelihood that the process improvement plan suggested will not fail. Additionally the role of the professional nurse in functioning as a leader in promoting quality care and influencing quality improvement activities will be discussed. A.Root Cause Analysis A root cause analysis (RCA) is “a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event” (Cherry & Jacob, 2011, p. 442). The people involved in the RCA should be the people involved in the scenario: the RN (Nurse J), the LPN, the physician (Dr. T.), the emergency room manager, and a figure from administration (Chief Nursing Officer?).
Nurses need to be educated on these indicators to understand the care they provide directly affects patient outcomes. The American Nurses Association (ANA) recognized areas of patient care and developed nursing-sensitive indicators to improve care of patients. Nursing-sensitive indicators reflect three aspects of nursing care: structure, process and outcomes. (American Sentinel University, 2011, para. 2) They identify structures of care and care processes, which influence patient care outcomes.
Nursing sensitive indicators reflect the structure, process and outcomes of nursing care. The structure of nursing care is indicated by the supply of nursing staff, the skill level of the nursing staff, and the education/certification of nursing staff. Process indicators measure aspects of nursing care such as assessment, intervention, and RN job satisfaction. Patient outcomes that are determined to be nursing sensitive are those that improve if there is a greater quantity or quality of nursing care. ("Nursing world," 2013) Knowledge of these indicators could have assisted the nurses in several ways involving this case.
In Monitor Alarm Fatigue: An Integrative Review, research evidence was broken down into themes including: effect of excessive alarms on staff, nurse’s response to alarms, alarm sounds and audibility, technology to reduce false alarms, and alarm notification systems. Non-research evidence revealed strategies to reduce alarm desensitization. Cvach concluded the article with evidence-based practice recommendations for technology manufacturers, hospitals, and caregivers. One nursing intervention recommended was to adjust alarm parameters so that they are customized to each individual’s actual needs. This intervention ensures that the alarms are valid and that they will provide and early warning to potential critical situations.