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One very important process improvement plan that could be utilized to decrease the likelihood of a reoccurrence of this sentinel event would be the institution of a time out prior to any procedural or “conscious” sedation taken place and utilizing a check sheet. In addition, there would be mandatory yearly training on the proper steps of all sedations that take place in the emergency department. We would then address the need to focus on the staffing ratios for the emergency department. The staff was over capacity and overwhelmed with just one high acuity critical patient that arrived by EMS. This one patient taxing their capabilities caused a lack of care for Mr. B resulting in a decline of his mental state, decreased respiratory drive, eventual causing cardiac arrest, then death. If a time out were preformed and a check list done prior to thissedation, proper cardiac and vital sign monitoring and oxygenation administration would have bedone and other equipment needed would be on standby.B1. Change TheoryIntegrating Lewin’s Change Model to the improvement plan will help the emergency department maintain the standard for conscious sedations going forward. The theory has three components that are unfreeze, change and refreeze. For the staff to understand how this change theory can be of assistance, they must understand the components of the theory. First, unfreezing is the process of searching out methods that allow the staff to dismiss previous unproductive was of doing things. The staff starts with adopting to the change and “unfreezing” their connection totheir current practice. This can be done with implementing this by communicating with the staff and sharing data/research. The second process is “change” where the actual change occurs. This can be a challenging stage due to staff frustrations, increase in questions, and need of extra support to grasp the concepts that need change. The third stage is “freezing” where the staff 05/31/2020
Organizational Systems Task 26transitions to the new state of doing things in the hospital. In this last stage there will be an activeneed to “refreeze” the new process so that it continues to conduct as intended. This stage ensure that staff will not return to the previous ways of doing things and this will involve employing new protocols and procedures. This will be reinforced by process checks, communication, and other formats to remind staff of the process improvement (Institute for Healthcare Improvement).C. General Purpose of FMEAA FMEA, Failure Modes and effect Analysis, tool helps determine the probability of a process and its success or failure rate. FMEA is a proactive systematic approach to evaluating a process and identify where and how it could fail. These asses the relative impact of multiple failures in order to identify the parts of the process that are most in need of change and correctingthe process proactively then waiting for an adverse or sentinel event to occur (Institute for Healthcare Improvement).