Root-Cause Analysis and Safety Improvement Plan Root-cause analysis (RCA) is a systematic method used to identify the underlying causes of adverse events or near misses in healthcare settings, aiming to prevent their recurrence and enhance patient safety (Singh, 2023). In this paper, I will conduct a root-cause analysis and develop a safety improvement plan for the issue of delayed response to deteriorating patient condition in an acute care setting. This issue is particularly critical in acute care environments where timely intervention can mean the difference between life and death.This analysis is vital for understanding the factors contributing to delayed responses and implementing effective strategies to mitigate risks and enhance patient …show more content…
These factors create an environment where patients at risk of deterioration may not receive timely interventions, resulting in adverse outcomes such as prolonged hospital stays, increased morbidity, and mortality. In my role as a nurse on an acute care floor, I encountered a patient who experienced a deteriorating condition, prompting the need to call a rapid response team (RRT). The patient, an elderly individual admitted for treatment of pneumonia, began to exhibit signs of respiratory distress, including increased respiratory rate, labored breathing, and oxygen saturation levels dropping to 80%. Despite administering supplemental oxygen and positioning the patient appropriately, their condition continued to worsen rapidly. As the primary nurse responsible for their care, I promptly recognized the urgency of the situation and initiated the appropriate protocols to activate the RRT. However, upon reflection and analysis of the event, several factors contributing to the delayed response became apparent. On that particular day, I was assigned to care for six patients, which further compounded the challenges of providing timely and comprehensive care to each individual. Therefore, due to high patient acuity …show more content…
Application of Evidence-Based Strategies Implementing evidence-based interventions is crucial in effectively addressing these challenges. Early warning scoring systems (EWSS) empower nurses to promptly identify signs of deterioration, facilitating timely intervention to prevent the worsening of a patient's condition. An EWSS consists of both input and output components. The input entails identifying patients whose condition is deteriorating and triggering an appropriate response. The output encompasses the response itself, which may involve heightened monitoring, assessment by a rapid response team, or transfer to the intensive care unit (Nagarajah et al., 2022). Rapid response teams (RRT) have emerged as a simple yet effective approach to tackling the primary factors contributing to Failure to Rescue (FTR). This includes deficiencies in monitoring and identifying patients at high risk of rapid clinical decline,
middle of paper ... ... Root Cause Analysis in Response to a Sentinel Event. Retrieved on March 2014 from world wide web at http://www.pedsanesthesia.org/meetings/2004winter/pdfs/heitmiller_Sentinel.pdf Orlando Regional Healthcare, Education & Development. (2004). Patient Safety: Preventing Medical Errors.
Noticeable indications of deterioration have been shown in numerous patients few hours prior to a critical condition (Jeroen Ludikhuize, et al.2012). Critical condition can be prevented by recognizing and responding to early indications of clinical and physiological deterioration ( kyriacosu, jelsma,&jordan (2011). According to NPSA (2007) delay in responding to deteriorating vital signs have been defined as an complication resulting in prolonged length of stay, disability or death, not attributed to the patient's underlying illness procedure along but by their health-care management ( Baba-Akbari Sari et al. 2006; Helling, Martin, Martin, & Mitchell, 2014). A number of studies demonstrate that changes or alterations in a patient’s
On May 20th, the patient, Mr. Ard, experienced nausea, shortness of breath, and pain while being treated in the hospital (Pozgar, 2014). The patient’s wife, Mrs. Ard, attempted many times to reach a nurse by pressing the nurse call button (Pozgar, 2014). Once the nurse finally responded, anti-nausea medication was administered (Pozgar, 2014). Mrs. Ard continued to monitor her husband’s situation, and felt as if the nausea and shortness of breath were getting worse (Pozgar, 2014). Mrs. Ard continued to ring the nurse call button for approximately 1.25 hours prior to a response from a nurse (Pozgar, 2014). A code was called, and Mr. Ard did not survive (Pozgar, 2014).
With patient safety always being the number one priority FTR is the worst case scenario for the hospitalized patient. In an article titled “Failure to Rescue: The Nurse’s Impact” from the Medsurg Nursing Journal author Garvey explains ways FTR can occur “including organizational failure, provider lack of knowledge and failure to realize clinical injury, lack of supervision, and failure to get advice.” Nurses are problem solvers by nature, they heal the sick and help save lives. FTR is a tragic experience for everyone involved. The recent surge in this happening across the country has given FTR cases widespread media coverage. Hospitals are trying to figure out what the root cause is and how they can be prevented. Fortunately, with the advancement of technology and extensive research many hospitals have developed action plans and procedures to help prevent the early warning signs from being
Featherstone, P., Prytherch, D., Schmidt, P., Smith, G. (2010). ViEWS: towards a national early warning score for detecting adult inpatient deterioration. Resuscitation, 81(8), 932-937.
Emergency room nurses have to be quick to adapting to any type of situation presented – within minutes, it can go from slow to hyper drive. Their main focus is not on one specific group but on
Considering the conflicting findings amongst the different EWS, it remains unknown whether these scoring systems are effective in identifying and responding to deteriorating patient in acute hospital settings. This essay intends to establish how successful, if at all, the EWS in particular SHEWS is in identifying deteriorating patients in acute surgical hospital settings. In order to do this we will be returning to patient X, a 22-year-old Asian female with a diagnosis of acute pancreatitis. By comparing the evidence base to reality I hope to get a better understanding of how effective this tool is in identifying deteriorating patients.
In today’s complex and high pace health systems, the power of the individual is entirely ineffective compared to that of a highly efficient and collaborative team. However, these professional healthcare organization systems can be tarnished by the presence of “tribes” among nurses, physicians, students, and etcetera. “Tribal culture” is literally a metaphor for groups that emphasize the exclusion of outside members into their “cliques.” In the movie “The Faces of Medical Error…from tears to transparency – The Story of Lewis Blackman”, there was a lack of communication and no transparency between different departments of the hospital. In Blackman’s case, the tribal culture led to the nurses failing to communicate vital health information to the physicians and patients, which eventually led to Blackmans death. So whether there are cliques of nurses, physicians, or even sub groups within each, the presence of them suppresses teamwork and collaboration. This will ultimately lead to compromised patient care, disgruntled staff, and high nurse turnover. Hook your themes here.
• Adverse events: An unintentional act that does not accomplish its outcome such as medication errors and adverse drug events or reactions. • Hazardous Condition: It is any set of conditions, which considerably increases the likelihood of a severe physical or mental adverse patient outcome without the disease or situation for which the patient is being treated for. • Sentinel Event: Is a sudden event comprising death or severe physical or mental injury or the risk. It includes any process variation for which a repetition would significantly carry a chance of serious adverse outcome e.g. loss function. • Root Cause Analysis: It comprises of Investigation, Analysis, Coordination and Reporting of incidence or sentinel occurrence which the results are forwarded to Patient Safety Committee and is the reviewed by appropriate entities for further, in-depth evaluation, review and responses for
JB McKenzie, et al. "STRATEGIES USED BY CRITICAL CARE NURSES TO IDENTIFY, INTERRUPT, AND CORRECT MEDICAL ERRORS." American Journal of Critical Care 19.6 (2010): 500-509. CINAHL Plus with Full Text. EBSCO. Web. 7 Mar. 2011.
A root cause analysis is a systematic approach utilized to identify problems within an event and create a plan for preventing that problem from recurring in the future. To be effective, a timeline of the events are created to help identify those areas that may be the reason for the problem or event, and the relationship between the causal factors and those factors identified to be a reason for the event to have occurred.
Evidence-based practice (EBP) is a process, a clinical master tool, so to speak, used by the nurse who is focused on positive outcomes in patient care. Registered Nurses (RNs), that assume a leadership role, continuously assess their practice in order to find out what is working and what is lacking or in need of more information (Barry, 2014). The RN who uses EBP strives to prevent healthcare errors, critically thinking through processes and anticipating obstacles, methodically drawing upon clinical research and expertise, including their own knowledge and drawing upon the individual patient experience toward improving safety and quality care (Barry, 2014). This systematic approach sets the RN apart from others, who may otherwise be tempted to remain stuck in old ineffective routines, and allows the RN the unique opportunity to affect change, most importantly, change that is directed toward keeping patients safe and receiving the best quality care (Barry, 2014).
One of the pivotal roles of a nurse is the ability to recognise patient deterioration. The skill of identifying crucial elements of deterioration and acting appropriately is fundamental for positive patient outcome. A vital skill performed primarily by nurses is the act of respiratory rate measurement. This skill is performed in addition to five other physiological parameters, which form a basis for a scoring system. The scoring systems commonly used are known as NEWS (National Early Warning Score) and EWS (Early Warning Score). As many adverse events are preceded by a period of time where by the patient exhibits physiological dysfunction, there is often time to correct abnormalities. This has significance for nurses, as they are responsible
The nursing discipline embodies a whole range of skills and abilities that are aimed at maximizing one’s wellness by minimizing harm. As one of the most trusted professions, we literally are some’s last hope and last chance to thrive in life; however, in some cases we may be the last person they see on earth. Many individuals dream of slipping away in a peaceful death, but many others leave this world abruptly at unexpected times. I feel that is a crucial part to pay attention to individuals during their most critical and even for some their last moments and that is why I have peaked an interest in the critical care field. It is hard to care for someone who many others have given up on and how critical care nurses go above and beyond the call
For any clinical decision related to any specific situation, only evidence alone never works. It also required good judgment, clinical expertise, awareness of patient’s preferences and needs (Kathleen M. Williamson et al.2015. Eizenberg , M,M . 2010). Complications in Critical Care areas to resolve need expert nurses who able to identify and manage the patient’s condition on time according to the situation. Health care provision in multifaceted circumstances, to reduce the patient’s length of stay in hospital, use of complicated machinery and client demand for quality care required smart significant decision making by nurses which result in better health care outcome and this critical thinking comes through EBP (Shoulders, B et al .