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event. The team then develops a causal statement related to each cause identified. The causal statements consist of three parts, the cause, the effect of the cause and how it relates to the event. The team then takes those causal statements and generates recommendations to prevent recurrence of the sentinel event. And finally, the team writes a summary of the RCA and shares itwith facility leadership, staff and any others who may be affected by the event or proposed recommendations [Ins10]. Some possible recommendations for this scenario could include, retraining ER staff on sedation policies including proper dosing of medications used for sedation.Creating a sedation safety checklist to ensure critical elements such as continuous B/P, ECG and pulse oximetry are not overlooked. Retraining staff on importance of monitor alarms and follow thought of reporting abnormal findings to appropriate care provider. Creating staffing guidelines 3
TASK 2 so it is clear when additional staff should be called in or adding additional staff to shifts.B1. Change TheoryLewin’s change theory lists three stages: stage 1 unfreezing; stage 2 moving; and stage 3 refreezing [Che14]. Stage 1 unfreezing involves making others aware that a change is needed, helping individuals adapt and understand why the change is necessary and how the change will be done [Che14]. The process improvement team accomplishes this by making staff aware of the sentinel event and how current practices directly lead to the event therefore, a change of current practices is necessary. The team introduces the planned changes, addition of a sedation safety checklist and new staffing guidelines. Stage 2 moving stage is where the change is actually implemented [Che14]. It is at this stage that the staff would actually begin to use the sedation safety checklist for patients receiving sedation in the ER and implementing new staffingguidelines, either additional staff on each shift or utilizing guidelines that stipulate when additional staff should be called in. It is during the moving stage that leadership needs to be available to help support and guide staff through the process. Stage 3 unfreezing, stage where theimplemented change becomes status quo [Che14]. This is where the new changes, sedation safety checklist and new staffing guidelines are consistently being used and followed. Improvement team can follow up on implemented changes by doing chart audits of patients receiving sedation in ER to see compliance rate of using sedation safety checklist and using staffing reports to determine if appropriate staffing levels are being maintained. 4
TASK 2 C.FMEAFailure mode and effects analysis (FMEA) is a process used to identify potential failures. FMEA is used in healthcare to improve the quality of care and minimize harmful errors to patients[Sau131]. There are 7 steps to the FMEA process. The first step is to identify a process toevaluate with FMEA. Second is assembling a multidisciplinary team. Third is to have the team list all the steps to the process being evaluated. Fourth, having the team identify potential failure modes. Fifth, assign a risk priority number (RPN) to each failure mode that represents the likelihood of that failure occurring, likelihood of detection and severity should that failure occur.