data, and then planning how to improve the process (IHI.org, n.d.). During the first step the new process that is being proposed is analyzed. The new process is most likely being planned due to a problem already existing. In this scenario, a new process is being proposed due to a patient going into respiratory arrest following a moderate sedation procedure. In the second step, a multidisciplinary team is created. Included in the team would be employees who are affected by the process being analyzed. The multidisciplinary team for this FMEA would therefor include nurses, doctors, pharmacists, respiratory therapists, as well as nurse educators. In the third step, the process would be clearly described and went over ensuring comprehension by all the team members. This is important to do in order to make sure everyone is on the same page, has the same understanding, and can have any questions clarified. During the fourth step, all potential failures that occur would be determined. This step is especially important to have the multidisciplinary team for as different team members might have different points in the process at which they might fail. It allows collaboration and team building to help ensure the new process will be as successful as possible (IHI.org, n.d.). In step five using risk priority numbers from 1-10, failures are scored for severity. This helps to create a clearer picture of the possible failures that are most serious and helps to set priorities for what should be improved upon. The failures with the highest severity scores are what should be focused on due to being most likely to occur. Step six involves evaluating the results of your data. This step is where the multidisciplinary team decides how to re-design and change the processes at the highest risk of failure. In this step it may be helpful to use a flow chart of the processes, identifying exactly where in the process the failure is likely to happen. It can then be
C489 TASK 2 9 compared to other flowcharts. The seventh and final step is to plan how to improve the process. This is where the process can be re-measured for failures, determine if the process changes help to mitigate the failures, and measure the outcome of the changes being made (IHI.org, n.d.) C2. FMEA Table See attached FMEA table. D. Intervention Testing The interventions from the process improvement plan would be tested using the Plan Do Study Act or PDSA cycles. PDSA cycles are beneficial for testing a change due to being able to repeat the PDSA cycles, allowing adjustment as necessary if the outcome does not meet expectations (IHI.org, n.d.). The objective of our interventions is to prevent unnecessary harm to patients who are receiving moderate sedation. The plan is to implement interventions for procedural and practice changes that include the following: -A nurse must remain present with any patient under moderate sedation until they are deemed physiologically stable based on vital signs and level of consciousness.
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- Summer '20
- Nursing, Root cause analysis, RCA