Cash-back offer from March 22nd to 31st, 2024: Get a flat 10% cash-back credited to your account for a minimum transaction of $50.Post Your Questions Today!

Question DetailsNormal
$ 10.00

Root Cause Analysis (RCA) and Failure Mode & Effects Analysis (FMEA)

Question posted by
Online Tutor Profile
request

It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient, arrives at the six-room emergency department (ED) of a
sixty-bed rural hospital. He has been brought to the hospital by his son and neighbor. At this time, Mr. B is moaning and
complaining of severe pain to his (L) leg and hip area. He states he lost his balance and fell after tripping over his dog.
Mr. B was admitted to the triage room where his vital signs were B/P 120/80, HR-88 (regular), T-98.6, and R-32, and his
weight was recorded at 175 pounds. Mr. B. states that he has no known allergies and no previous falls. He states, “My hip
area and leg hurt really bad. I have never had anything like this before.” Patient rates pain at 10 out of 10 on the numerical
verbal pain scale. He appears to be in moderate distress. His (L) leg appears shortened with swelling (edema in the calf),
ecchymosis, and limited range of motion (ROM). Mr. B’s leg is stabilized and then is further evaluated and discharged

from triage to the emergency department (ED) patient room. He is admitted by Nurse J. Nurse J finds that Mr. B has a
history of impaired glucose tolerance and prostate cancer. At Mr. B’s last visit with his primary care physician, laboratory
data revealed elevated cholesterol and lipids. Mr. B’s current medications are atorvastatin and oxycodone for chronic back
pain. After Mr. B’s assessment is completed, Nurse J informs Dr. T, the ED physician, of admission findings, and Dr. T
proceeds to examine Mr. B.
Staffing on this day consists of two nurses (one RN and one LPN), one secretary, and one emergency department
physician. Respiratory therapy is in-house and available as needed. At the time of Mr. B’s arrival, the ED staff is caring for
two other patients. One patient is a 43-year-old female complaining of a throbbing headache. The patient rates current
pain at 4 out of 10 on numerical verbal pain scale. The patient states that she has a history of migraines. She received
treatment, remains stable, and discharge is pending. The second patient is an eight-year-old boy being evaluated for
possible appendicitis. Laboratory results are pending for this patient. Both of these patients were examined, evaluated,
and cared for by Dr. T and are awaiting further treatment or orders.
After evaluation of Mr. B, Dr. T writes the order for Nurse J to administer diazepam 5 mg IVP to Mr. B. The medication
diazepam is administered IVP at 4:05 p.m. After five minutes, the diazepam appears to have had no effect on Mr. B, and
Dr. T instructs Nurse J to administer hydromorphone 2 mg IVP. The medication hydromorphone is administered IVP at
4:15 p.m. After five minutes, Dr. T is still not satisfied with the level of sedation Mr. B has achieved and instructs Nurse J
to administer another 2 mg of hydromorphone IVP and an additional 5 mg of diazepam IVP. The physician’s goal is for the
patient to achieve skeletal muscle relaxation from the diazepam, which will aid in the manual manipulation, relocation, and
alignment of Mr. B’s hip. The hydromorphone IVP was administered to achieve pain control and sedation. After reviewing
the patient’s medical history, Dr. T notes that the patient’s weight and current regular use of oxycodone appear to be
making it more difficult to sedate Mr. B.
Finally, at 4:25 p.m., the patient appears to be sedated, and the successful reduction of his (L) hip takes place. The
patient appears to have tolerated the procedure and remains sedated. He is not currently on any supplemental oxygen.
The procedure concludes at 4:30 p.m.,and Mr. B is resting without indications of discomfort and distress. At this time, the
ED receives an emergency dispatch call alerting the emergency department that the emergency rescue unit paramedics
are enroute with a 75-year-old patient in acute respiratory distress. Nurse J places Mr. B on an automatic blood pressure
machine programmed to monitor his B/P every five minutes and a pulse oximeter. At this time, Nurse J leaves Mr. B’s
room. The nurse allows Mr. B’s son to sit with him as he is being monitored via the blood pressure monitor. At 4:35 p.m.,
Mr. B’s B/P is 110/62 and his O2 saturation is 92%. He remains without supplemental oxygen and his ECG and
respirations are not monitored.

Nurse J and the LPN on duty have received the emergency transport patient. They are also in the process of discharging
the other two patients. Meanwhile, the ED lobby has become congested with new incoming patients. At this time, Mr. B’s
O2 saturation alarm is heard and shows “low O2 saturation” (currently showing a saturation of 85%). The LPN enters Mr.
B’s room briefly, resets the alarm, and repeats the B/P reading.
Nurse J is now fully engaged with the emergency care of the respiratory distress patient, which includes assessments,
evaluation, and the ordering of respiratory treatments, CXR, labs, etc.
At 4:43 p.m., Mr. B’s son comes out of the room and informs the nurse that the “monitor is alarming.” When Nurse J
enters the room, the blood pressure machine shows Mr. B’s B/P reading is 58/30 and the O2 saturation is 79%. The
patient is not breathing and no palpable pulse can be detected.
A STAT CODE is called and the son is escorted to the waiting room. The code team arrives and begins resuscitative
efforts. When connected to the cardiac monitor, Mr. B is found to be in ventricular fibrillation. CPR begins immediately by
the RN, and Mr. B is intubated. He is defibrillated and reversal agents, IV fluids, and vasopressors are administered. After
30 minutes of interventions, the ECG returns to a normal sinus rhythm with a pulse and a B/P of 110/70. The patient is not
breathing on his own and is fully dependent on the ventilator. The patient’s pupils are fixed and dilated. He has no
spontaneous movements and does not respond to noxious stimuli. Air transport is called, and upon the family’s wishes,
the patient is transferred to a tertiary facility for advanced care.
Seven days later, the receiving hospital informed the rural hospital that EEG’s had determined brain death in Mr. B. The
family had requested life-support be removed, and Mr. B subsequently died.
Additional information: The hospital where Mr. B. was originally seen and treated had a moderate sedation/analgesia
(“conscious sedation”) policy that requires that the patient remains on continuous B/P, ECG, and pulse oximeter
throughout the procedure and until the patient meets specific discharge criteria (i.e., fully awake, VSS, no N/V, and able to
void). All practitioners who perform moderate sedation must first successfully complete the hospital’s moderate sedation
training module. The training module includes drug selection as well as acceptable dose ranges. Additional (backup) staff
was available on the day of the incident. Nurse J had completed the moderate sedation module. Nurse J had current
ACLS certification and was an experienced critical care nurse. Nurse J’s prior annual clinical evaluations by the manager
demonstrated that the nurse was “meeting requirements.” Nurse J did not have a history of negligent patient care.
Sufficient equipment was available and in working order in the ED on this day.

REQUIREMENTS
Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a
10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited
correctly. An originality report is provided when you submit your task that can be used as a guide.
You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to
evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles
may contain hyperlinks to relevant portions of the course.
A. Explain the general purpose of conducting a root cause analysis (RCA).
1. Explain each of the six steps used to conduct an RCA, as defined by IHI.
2. Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel
event outcome.
B. Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome.
1. Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed
improvement plan.
C. Explain the general purpose of the failure mode and effects analysis (FMEA) process.
1. Describe the steps of the FMEA process as defined by IHI.
2. Complete the attached FMEA table by appropriately applying the scales of severity, occurrence, and detection to
the process improvement plan proposed in part B.
Note: You are not expected to carry out the full FMEA.
D. Explain how you would test the interventions from the process improvement plan from part B to improve care.
E. Explain how a professional nurse can competently demonstrate leadership in each of the following areas:
• promoting quality care
• improving patient outcomes
• influencing quality improvement activities

1. Discuss how the involvement of the professional nurse in the RCA and FMEA processes demonstrates leadership
qualities.
F. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or
summarized.
G. Demonstrate professional communication in the content and presentation of your submission.
File Restrictions
File name may contain only letters, numbers, spaces, and these symbols: ! - _ . * ' ( )
File size limit: 200 MB
File types allowed: doc, docx, rtf, xls, xlsx, ppt, pptx, odt, pdf, txt, qt, mov, mpg, avi, mp3, wav, mp4, wma, flv, asf, mpeg,
wmv, m4v, svg, tif, tiff, jpeg, jpg, gif, png, zip, rar, tar, 7z

Available Answer
$ 10.00

[Solved] Root Cause Analysis (RCA) and Failure Mode & Effects Analysis (FMEA)

  • This solution is not purchased yet.
  • Submitted On 15 Oct, 2021 09:18:26
Answer posted by
Online Tutor Profile
solution
A. Explain the general purpose of conducting a root cause analysis (RCA). The root cause analysis is typical terms that are used to represent the different methods, resources, and approaches that are used to know the origin of an issue. The primary objective for the use of such an analysis is to differentiate the root causes and to create the systematic methods that are applicable in case the need arises (Charles et al., 2016). For efficient management in the medical facilities, root cause analysis fosters the discovery of the factor that cause risks to the patients in the medic...
Buy now to view the complete solution
Other Similar Questions
User Profile
Assig...

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Your assignment is attached. Thanks for purchasing this assignment! ...
User Profile
termp...

NURS 4020 assessement 2 1.docx NURS 4020 Root cause analysis patient safety improvement

NURS 4020 assessement 2 1.docx NURS 4020 Root cause analysis patient safety improvement plan Capella University NURS 4020: Improving quality care patient safety Patient Safety Patience safety refers to reducing the perc...
User Profile
termp...

ORGSYS5.docx A. Root cause analysis (RCA) is a system used to determine the root cause o

ORGSYS5.docx A. Root cause analysis (RCA) is a system used to determine the root cause of an adverse event. The system also determines ways to effectively handle the event. The general purpose of conducting a root cause ana...
User Profile
termp...

MHACB_505_Competency_3__Part_1_Root_Cause_Analysis.docx Root Cause Analysis University

MHACB_505_Competency_3__Part_1_Root_Cause_Analysis.docx Root Cause Analysis University of Phoenix MHACB/505 Root Cause Analysis Within a Gemba walk, problems were found to have short term effects, the lack of water for...
User Profile
termp...

C489T2.docx C489 Task 2: RCA and FMEA Western Governors University A.Root Cause Anal

C489T2.docx C489 Task 2: RCA and FMEA Western Governors University A.Root Cause Analysis (RCA) Root cause analysis is used to find an underlying cause of a problem through a multi-step process. When there is no easy fi...

The benefits of buying study notes from CourseMerits

homeworkhelptime
Assurance Of Timely Delivery
We value your patience, and to ensure you always receive your homework help within the promised time, our dedicated team of tutors begins their work as soon as the request arrives.
tutoring
Best Price In The Market
All the services that are available on our page cost only a nominal amount of money. In fact, the prices are lower than the industry standards. You can always expect value for money from us.
tutorsupport
Uninterrupted 24/7 Support
Our customer support wing remains online 24x7 to provide you seamless assistance. Also, when you post a query or a request here, you can expect an immediate response from our side.
closebutton

$ 629.35