The fourth step is the development of causal statements with three parts including cause, effect and event. The actual statement is created by connecting the cause to the effect (step three back to the primary event the statement (step one). This step allows the identification of “how” and “why” the outcome occurred. Step five is the generation of a list of recommendations to prevent the recurrence of the event. IHI lists categories which are often used within the process. The categories of recommendations are standardizing equipment, ensuring redundancy, using forcing functions to physically prevent mistakes, changing physical plant, software improvement, using cognitive aids, process simplification, staff education and policy development (App.ihi.org, n.d.). It is also important to concentrate on the strength of the action as this will determine the likelihood of reducing events. Strong actions are the most likely to reduce events, intermediate are for controlling the root cause or vulnerability while weak is least effective. The sixth and last step is to summarize the steps for improvement and present to others Creating a visual representation of the change process, such as creating a flowchart or fishbone diagram, allows for the information to resonate more effectively. Involving key team members
Running head: Organizational Systems Task 2 4 Updated: 2/1/19 in the presentation and implementation of the summary will help to continue process improvement. A2. Causative and Contributing Factors Mr. B arrived at the emergency department at 3:30 p.m. with a primary complaint of severe hip pain after a fall, reported at 10/10. At 4:43 p.m. he was pulseless and not breathing. When Mr. B was admitted to the emergency room, his affected right leg was edematous, ecchymotic, shorter than the left and had limited range of motion. Nurse J performs the assessment and reviews patient history, then reports to Dr. T. There is no chart review by the physician prior to Mr. B’s assessment. Pain medication is not administered until forty-five minutes after Mr. B arrived at the hospital. His primary concern for severe pain was not addressed. Mr. B was sedated at 4:23 p.m., but not on supplemental oxygen, with no cardiac monitoring and no pulse oximetry applied. Mr. B’s blood pressure and oxygen were not monitored until post-procedure at 4:35 p.m., however there still was no ECG or respiratory monitoring. Mr. B was left unattended by the nurse because the department was short staffed, and she was busy with a critical patient. When the oxygen saturation alarmed that it was low, rather than assessing the patient and/or increasing the oxygen as needed, the LPN arrived and only reset the alarm without communicating findings to Nurse J.
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- Fall '18
- Root cause analysis, Failure mode and effects analysis, Mr. B