an event from happening. With this scenario, current policies were in place to help keep the patient free from harm, but were not followed. If the equipment and alarms were used correctly, detection could have been known earlier and proper interventions taken. Detection rates how well the current procedures are working. In this case, they are not being followed properly, therefore putting it on a higher rating of events being detected. C2. See attached
C489 RCA and FMEA Task 210D. Using the Plan Do Study Act (PDSA) module of implementing a process improvement plan, the Study portion is where we would study the results of new or revised policies. The PDSA level measures specific changes to reaching a goal. Measurement is an important part of the change. This tells if the changes are leading to improvement. For the changes with measurable outcomes, we could plot data and do a run chart of the information. (Provost, Lloyd & Murray, 2016) For testing the intervention of adverse sedation reaction, we can measure a random sample of ten patients that received conscious sedation every month. With this information, looking for triggers and events that may have happened. We would record the number of patients receiving conscious sedations medication, the number of doses and milligrams given and plot this with any interactions they may have had. If adverse reactions werenoted, it could be looked at deeper to see if there are similar underlying causes for these individuals that would be comparable. Checking the random sample, a positive outcome would be that with putting a medication reconciliation and patient home medication interview in place, there were no adverse reactions. To test the proper use of continuous monitoring, this can be recorded and observed by the nurse manager. Without prior knowledge to the nurse assigned to post conscious sedation patients, observations can be done at the bedside to see if proper monitoring of the patient’s B/P, oxygen saturation, and ECG are being done. Surveys can be usedto test implementation of encouraging communication and timely reporting and care team development & satisfaction with change. The survey would be used for all staff on the unit, including physicians, involved in the process of the improvement plan. This can give informationthat individuals would otherwise withhold if they did not feel comfortable sharing while getting honest answers of how the plan is working. This will give results of how staff feel
C489 RCA and FMEA Task 211communication is working, and how physicians and lead nurses feel important information is being relayed to them in a timely manner. Encouragement for communication and participation in training and journal reviews can be recorded by sign in sheets and reports given on evidence found from reviews. Staff could be asked to report back by a certain time, after reviewing journalinformation, to give thoughts on best evidence based practices compared to current facilities working procedures. The new plan needs to be tested for adherence to the new or revised practice
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- Fall '19
- Failure mode and effects analysis, RCA