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measures I would take to correct this would be when administering mild to moderate sedation immediately get an order to put patient on telemetry as well as making sure that there is appropriate number of staff so that the patient could be monitored accordingly. Also change the policy, to include the appropriate number of staff. I also would suggest having a mandatory meeting with the department to retrain or discuss the policy on mild/moderate sedation. Finally, write a summary and share it with the department and other staff member. Provide a flow chart with pictures and the events that led to the occurrence and how to move forward to keep it from happening again.B.Propose a process improvement plan that would decrease the likelihood of a
reoccurrence of the scenario outcome.A proposed process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome would be to recommend educating the staff and have the staff review the policy on mild/moderate sedation and to offer re-educating staff every 3 to 6 months. I also would implement changes to the policy such as if a nurse is taken care of one patientunder mild/moderate sedation he or she is not allowed to take care of another patient requiring high acuity care. I would also suggest the nurse do frequent rounding of these patients and have the nurse or PCT complete vital signs every 15 minutes so that they can accurately identify any changes.B1. Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan.Lewin’s change theory is made up of three phases: Unfreezing, change, and freezing. During the Unfreezing stage, this is where an individual or team is helping the staff understand why change is necessary and stating how the change will be accomplished. I would do this by giving details on what happened from the LPN not communicating to Nurse J. not following up with patient after administering medication. I would include how the previous policy had not worked effectively regarding mild/moderate sedation and provides detail to why the policy need to be changed to prevent events like this from happening again. In the change stage, this is where something is actually happening. The nurses are doing their rounding more frequently. The nurse is now taking BP more frequently and if the nurse is not able to monitor the vitals within 15 minutes, she would delegate a patient tech to take the vitals and report values to her withing a timely manner. I have asked for other administrative team to assist with other duties to free the nurse. In my proposed plan, this would
require discussing round improvements, staff views, and providing the details, so it was more comfortable for the workers to meet. If the team monitor the vitals/data as frequent, this will lead to behavior change. The last stage is freezing. This is making sure people do not return to the old habits. This could be done in the proposed strategy by monitoring staff after being reeducated on the new changes in the policy on mild/moderate sedation. This will identify if the staff is consistent and have adequate staff to implement the changes. Also,