room with a nurse or Chaplin off to the side out of the way to comfort him and explain what is being done. By the time a heart rhythm is resuscitated 11
TASK 2 RCA AND FMEA the patient has been without oxygen too long, he had been decompensating for 20 minutes. This was a completely avoidable tragic circumstance. Conscious sedation policy was not followed. B. Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome. According to IHI there are four distinct phases of an improvement plan which is the complete “life cycle”. Innovation-coming up with new ideas for change, Pilot-testing a change on a small scale, Implementation- making the change the new standard process in a defined setting and Spread- implementing the change to several settings. Starting with the innovation phase, there are many factors to be changed and new ideas to be improved and implemented for this adverse scenario. There were several areas for change we can work on. Due to the tragic nature of this scenario I would first suggest a debrief with the 12
TASK 2 RCA AND FMEA departments and staff involved in a guilt free safe way. Then we should come up with a new policy for conscious sedation including a complete review of patient’s health history including prior to admission medications, current vital signs, monitoring requirements, medication appropriateness for all ages including height and weight requirements, Dr.’s credentials for sedation verified, ACLS certified nurse and physician present, and criteria for discharge. Also, if the nurse is involved with procedure or performing the sedation they are not allowed to be assigned to other duties or responsibilities that would compromise them adequately monitoring the patient before, during or after the procedure. Some new staff education would be appropriate changes as well. If staff are not ACLS certified they will receive that training if sedation takes place in the department they work. All staff in sedation roles would receive specialized training in conscious 13
TASK 2 RCA AND FMEA sedation practices and policies. An annual skills day could prove to be a helpful tool in reviewing skills. Staffing for the departments with sedation capabilities should be enhanced for such occurrences or the patient should be transferred to a unit that has staff to monitor conscious sedation patients appropriately before, during and after procedure. I would pilot test this plan in one hospital unit to see how things work or don’t work. I would try to work out some of the kinks before moving it to other units. Once consensus of a successful new process is completed, I would Implement the new process to one unit at all the hospitals. Then we would spread this new improvement model to all units of the hospital conducting conscious sedation.
You've reached the end of your free preview.
Want to read all 31 pages?
- Fall '19
- Failure mode and effects analysis, RCA, IHI