Process and outcome measures ensure that interventions have been carried out

Process and outcome measures ensure that

This preview shows page 5 - 8 out of 9 pages.

Process and outcome measures ensure that interventions have been carried out and assess the effectiveness on desired outcomes. This is where system and process errors are revealed as contributing factors when combined with human errors. These results are then used by those that can take action to prevent similar events from reoccurring. Leadership support is imperative before, during, and after any probable or known RCA. This ensures that required information is dispersed to those participating in the RCA and any interventions or policy changes are authorized by those with the power and resources that are needed. Improvement Plan The proposed plan is to place all patients on continuous monitoring equipment including B/P, EKG, and pulse oximeter while under care in the ED. During triage, patients are placed on monitoring equipment and continue through the care process. In the case of Mr. B he would have already been on this equipment prior to the start of the sedation procedure. Once the procedure was complete the continuous monitoring equipment would have given a clearer picture of Mr. B’s status to the care team. When a decline in the patient’s status is alerted on the monitor interventions could have been performed to prevent further patient decline and the ultimate demise of Mr. B. Change Theory When introducing a change in the ED process, a staff meeting would allow everyone to express questions, concerns, or advice about the change. An online module or physical hands on training would also allow for staff encouragement and support. Once the change occurs and all Updated: 2/1/19
Image of page 5
Running head: Organizational Systems Task 2 6 staff members are enacting the change, continued reinforcement is established through periodic audits or process checks. Also, as a part of new staff orientation a baseline expectation is established through training in current policies and procedures. This safeguards against experienced staff shifting back to previous culture, as the new staff will need guidance and support in their transition to ED practice standards of care. General Purpose of FMEA The general purpose of Failure Modes and Effects Analysis (FMEA) is to provide a proactive method for evaluating a new process, or process change, for possible failures to reduce risks to patients and staff (FMEA, 2017) Steps of FMEA Process During a FMEA review the steps of the process, or process change, are listed so that risk can be evaluated (FMEA, 2017). Then failure modes, failure causes, and failure effects are considered (FMEA, 2017). These look for what can go wrong, why would it occur and what could be the results of such a failure. FMEA Table Table noted as additional to this document. Intervention Testing Based on the FMEA table, the highest risk priority number (RPN) is given to the initial step in the improvement plan, placing patients on monitoring devices upon triage. This should be the primary focus in refining the intervention to improve patient care. Although this is a small community hospital, perhaps they have a monitoring department that can watch patient devices independent of the beside. This would allow for a second check that monitoring equipment is Updated: 2/1/19
Image of page 6
Running head: Organizational Systems Task 2 7 connected to the patient and functioning properly. By providing this “double check” it reduces
Image of page 7
Image of page 8

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture