Additional information: The hospital where Mr. B. was originally seen and treated had a moderate sedation/analgesia policy that requires that the patient remains on continuous B/P, ECG, and pulse oximeter throughout the procedure and until the patient meets specific discharge criteria. All practitioners who perform moderate sedation must first successfully complete the hospital’s moderate sedation training module. The training module includes drug selection as well as acceptable dose ranges. Additional staff was available on the day of the incident.
A. Explain the general purpose of conducting a root cause analysis (RCA).
1. Explain each of the six steps used to conduct an RCA, as defined by IHI.
2. Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome.
B. Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome.
1. Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan.
C. Explain the general purpose of the failure mode and effects analysis process.
1. Describe the steps of the FMEA process as defined by IHI.
2. Complete the attached FMEA table by appropriately applying the scales of severity, occurrence, and detection to the process improvement plan proposed in part B.
D. Explain how you would test the interventions from the process improvement plan from part B to improve care.
