SAT1 Organizational Systems and Quality Leadership Paper

Organizational Systems and Quality Leadership SAT Task 2

  1. Root Cause Analysis

A systematic tool used by healthcare professionals to study how and why a problem occurs and how to prevent the problem from happening again.

A1. There are six steps to most RCAs:

 Step 1: Identify what happened. In this step the team gathers information and describes what happened. A flow chart is developed to draw a picture of the incident in the order that occurred.

SAT1 Organizational Systems and Quality Leadership Paper

Step 2: Determine what should have happened. The team identifies what

would have happened with the correct procedures were followed.

Step 3: Determine causes (“Ask why five times”). In this step, the team looks at the direct cause and contributing factors.

 Step 4: Develop causal statements. A causal statement links the cause to its effects and then back to the main event that prompted the RCA in the first place.

Step 5: Generate a list of actions or changes to prevent the recurrence of the event in the future.

Step 6: Write a summary and share it. This can be an opportunity to engage the key players to help drive the next steps in improvement.

A2. Causative and Contributing Factors

In this scenario, it appears the patient received too much sedation. In the 20 min documented, Mr. B received 10 mg of diazepam and 4mg of hydromorphone. Safe dosing practices were not implemented. After arriving to the room, Nurse J places Mr. B on an automatic blood pressure machine programmed for every five minutes and a pulse oximeter, then leaves the room. Because the patient was sedated, the nurse should have stayed in the room for the first 15 min to assess and monitor.  At 4:35pm, it was stated that the O2 sat was 92%. The patient was not placed on supplemental oxygen and his ECG and respirations are not monitored. Another contributing factor appears to be staffing. Staffing consisted of two nurses and an ER physician for patient care with more critical patients arriving by EMS.

  1. Improvement Plan

The improvement plan would begin with developing a team of multiple disciplinary healthcare members (i.e. Medical director, ER nurse manager, director of nursing, respiratory therapy) as a committee to perform a root cause analysis of the incident. The team will conduct interviews with the staff and perform records review to gather information on the occurrence. Contributing and direct factors would be identified. The team would identify what went wrong and develop a plan of action to prevent future occurrences.

B1. Change Theory

Change is crucial to the growth of a profession. Kurt Lewins change theory consist of three stages which include unfreezing, change and freezing. Unfreezing stage attempts to help people adjust to change or loosen an attachment to a specific practice or task. During this stage, the hospital directors and educational department can implement mandatory patient education sessions on conscious sedation and review the sentinel event that resulted in the death of a patient. A new EHR software module can be introduced with checkpoints and hard stop capability if too much medication is detected. Extensive training will be provided. During the second stage of change, the new change is implemented. Staff will need support with coping with the new change as frustration may occur. The new medication safety checklist software will be effective with super-users onsite to assist with training.

The third stage involves freezing which locks the change in place. Frequent checks are implemented to see how the new process is working. This prevents the change from being unsuccessful and returning to the old process. The committee will do performance evals and system review to ensure staffing is documenting correctly and no more sentinel events are reported.

  1. General Purpose of FMEA

According to the Institute for Healthcare Improvement, Failure Modes and Effects Analysis ( FMEA) is a systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change (

C1. Steps of FMEA Process

The FMEA tool allows teams to review, evaluate and record:

Review the process

  1. Failure mode. This consist of identifying anything that can go wrong during that step in the process.
  2. failure causes. In this step, list all possible causes for each of the failure modes that have been identified.
  3. Failure effects. The team will address all possible adverse consequences for each listed failure mode.
  4. Likelihood of occurrence. You will rate what is the likelihood the failure mode will occur on a scale of 1-10. 10 will be the most likely.
  5. Likelihood of detection. The likelihood the failure will not be detected if it occurs will be rated on a scale of 1-10 with 10 being the most likely.
  6. If the failure mode occurs, what is the likelihood that the failure mode will cause severe harm on a scale of 1-10. SAT1 Organizational Systems and Quality Leadership Paper
  7. Record the risk profile number
  8. Review the action to reduce the occurrence of failure. List possible actions to improve safety

C2. FMEA Table

Submitted as a separate document

  1. Intervention Testing

Intervention testing is a test pilot to improve care. The ED would be involved in the test pilot program. The test-pilot roll out would include a team made up of the ED Nurse Manager and Medical Director to observe 5-10 conscious sedation patients. Upon first notification by a physician that orders have been written for a conscious sedation procedure, the observation team would verify the time of response from order placement in the Electronic Health Record (EHR) by the prescribing provider to the acknowledgment by the RN.  The observation team would verify the time it takes the RN and RT to  arrive at the patient’s bedside with ECG, BP and Pulse Oximetry monitoring equipment.  Upon placement of the ECG, BP and Pulse Oximetry monitoring equipment, the team would then observe any challenges the RN or RT face in double verification before medication administration could occur.  Upon successful conscious sedation verification by the physician, the ordered procedure would begin and be completed by the physician and other providers, and monitoring would be continued by the RN and RT, to ensure continuous BP, ECG, and pulse oximetry monitoring is maintained until the patient is symptom free, fully awake, with VSS, no N/V, and able to void per hospital policy.

  1. Demonstrate Leadership

E1. Involving Professional Nurse in RCA and FMEA Processes

The discussion logically describes how the involvement of the professional nurse in both the RCA and FMEA processes demonstrates leadership qualities.

SAT 1 Organizational Systems and Quality Leadership Paper References

QI Essentials Toolkit: Failure Modes and Effects Analysis (FMEA) Tool. Institute for Healthcare Improvement; 2017. (Available on