Scenario: 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, & one emergency department physician. Respiratory therapy is in-house & 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, & 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 & 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, & alignment of Mr. B’s hip. The hydromorphone IVP was administered to achieve pain control & sedation. After reviewing the patient’s medical history, Dr. T notes that the patient’s weight & 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, & the successful reduction of his (L) hip takes place. The patient appears to have tolerated the procedure & remains sedated. He is not currently on any supplemental oxygen. The procedure concludes at 4:30 p.m., & 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 & his ECG and respirations are not monitored. Nurse J & 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 & 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 & no palpable pulse can be detected. A STAT CODE is called & the son is escorted to the waiting room. The code team arrives & begins resuscitative efforts. When connected to the cardiac monitor, Mr. B is found to be in ventricular fibrillation. CPR begins immediately by the RN, & Mr. B is intubated. He is defibrillated and reversal agents, IV fluids, & 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 & is fully dependent on the ventilator. The patient’s pupils are fixed & dilated. He has no spontaneous movements & does not respond to noxious stimuli. Air transport is called, & 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, & Mr. B subsequently died. Additional information: The hospital where Mr. B. was originally seen & 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 & 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 & 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 & in working order in the ED on this day. Instructions: Write a 10-12 page paper and fill out the FMEA table. A. Explain the general purpose of conducting a root cause analysis (RCA). (Use RCA guide attached & describe in own words). 1. Explain each of the six steps used to conduct an RCA, as defined by IHI. (list each step briefly & describe in own words) 2. Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome. (define causative and contributing factors – together or separately) (list several factors for each, & list which steps from the RCA process helped you determine these factors – not all steps need to be listed, just the steps that helped) B. Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome. (Based on the problems identified in section A2, what recommendations would you make to correct those probelms?) 1. Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan. (refer to txtbook listed below. Also describe Lewin’s change theory & the 3 phases & discuss how you would apply the 3 phases within your improvement plan (from Letter B)) C. Explain the general purpose of the failure mode and effects analysis (FMEA) process. (Use FMEA tool & watch video listed below) 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. (focus on improvement plan from letter B & not problems within the scenario- table should correlate w/ improvement plan from B. Can either be one theme w/ 4 steps in the process of 4 different steps (different improvements)) 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. (discuss the PDSA cycle & apply the PDSA cycle to one part of your plan from section B to explain how you would test these interventions) E. Explain how a professional nurse can competently demonstrate leadership in each of the following areas & give example • 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. Resources: FMEA video: https://wgu.hosted.panopto.com/Panopto/Pages/Viewer.aspx?id=675fb8c8-60db-49bd-a1e0-d2201cc45c05 Resource Information for Part B1: https://wgu.vitalsource.com/reader/books/9780323554206/epubcfi/6/62[%3Bvnd.vst.idref%3DCHP0017]!/4/2/34/16/14[p1450]/1:243[exi%2Cst%5E%2C] if you can’t access the information from the online book, let me know.