Organizational Failure Management Mentor
Organizationsand professionals may face certain situations that may have adverseimpacts on their activities and results. Even in events when all therequired standards and procedures are applied, unanticipatedsituations may still arise resulting in negative impacts. In thehealthcare organizations, sentinel events events that unexpected andmay lead to severe damages or death to the patient, are likely tooccur in the treatment process. In the case of any failure, instantanalysis and an improvement plan must be designed to avoid any futureoccurrence of the sentinel event. According to the Joint Commission,hospitals are required to conduct a Failure Mode and Effects Analysis(FMEA) to lower the chances of the failure of a medical process.Therefore, the essay seeks to assess the FMEA process undertaken toensure that the improvement plan does not fail.
Thesentinel events that resulted in the death of Mr. B were caused byfactors within the Emergency Department. First, an emergencydepartment should have sufficient facilities and physicians to handleany emergency, which may be in different forms and size. According tothe scenario, the ED department had only two on-duty nurses, whilethe patients were three. This shortage of personnel is the primarycause of the failure since the two nurses were overworked and thustheir chances of errors and fatigue were high. Additionally, the EDphysician DR.T is a very busy doctor who does not have the patienceto review the patient`s medical history and make right decisions. Hefailed to consider that Mr. B was under medication for chronic backpain and history of glucose tolerance and prostate cancer. All thesefactors could have resulted in the slow response to anesthesia orsedatives.
Onthe other hand, Dr. T may be regarded as a reckless physician whoneglects the patients regarding the procedure for treatment. Heordered the administration of diazepam, ten minutes later he againadminister hydromorphone and another 2mg of hydromorphone and 5 mg ofdiazepam after five minutes. This form of medication is an indicationthat the doctor does not consider overdosing the patient and actsrecklessly. On a similar note, the ED department practicedsignificant negligence they neglected Mr. B to be monitored by hisson, and when the oxygen level reduced, he remained withoutsupplemental oxygen without the monitoring of his ECG respirations.
Thenurses reset the oxygen saturation alarm rather than taking the timeto monitor the patient and report for immediate action or replacementof the oxygen supplement. Therefore, the nurses and physicians playeda significant role in causing the sentinel since they neglected thepatient and the usual standard of conscious sedation. The conscioussedation required that the patient must remain constant B/P, ECG andpulse oximeter throughout the treatment procedure.
Theprimary factor that would prevent such failures is the strictfollow-up and implementation of the hospital standards and codes ofconduct. The conscious sedation measures must be implemented, and anyphysician or nurse that breaks them should face dire consequences.Secondly, the facility should have proper staffing by increasing thenumber of nurses to eliminate the excess workload and chances ofnegligence. Additionally, the ED doctors should be properly trainedand assessed regularly to ensure they are in best condition to makeright decisions. For instance, after sedation Dr. T noted that thepatient was difficult to sedate due to weight and medical history,which he ought to have known before the overdose this is a sign ofnegligence and wrong decision-making.
Thechange theory for implementing the improvement plan is the KurtLewin`s change management theory that consists of three major stages.The three stages are the unfreezing, moving and refreezing (Burke,2013). In the unfreezing the stage, the hospital acknowledges thefailures and the need for change. After creating the awareness andthe need for the change, stakeholders are engaged in the movingstage, where they take action and propose the changes necessary. Inthe refreezing stage, the changes are implemented and made part ofthe routine procedures.
FailureModes and Evaluation Analysis (FMEA)
FailureModes and Evaluation Analysis (FMEA) is systematic and a proactivemethod for assessing a given process to determine the chances offailure and the effects of such failures (Ford et al., 2014). In thepreparation of FMEA, there are precise pre-steps applied, before theactual steps of the development. The pre-steps include identifyingthe steps in the process, whereby all the chronological steps arelisted. Secondly, identify the failure modes, whereby all thepossible problems are estimated. Thirdly, list the cause of theanticipated failures including the reasons why the failures mayoccur. Finally, evaluate the consequences of the failures identified(Ford et al., 2014).
Concerningthe scenario provided, the pre-steps will be applied in a manner thatall the medical procedures undertaken on the patient are listed. Theemergency physicians are supposed to assess all the necessary stepsregarding Mr. B`s situation, including proper diagnosis of thecurrent and past medical conditions. Once all the information aboutthe patient and the treatment procedure have been evaluated andlisted, the hospital can then identify the possible failures in theprocess. Based on the physicians` level of training, equipment,workload and the nature of the patient`s condition, potentialfailures in the treatment process are easily formulated.
Additionally,after listing all the possible factors that may lead to the failureand the actual failures, the hospital would then evaluate thepossible causes of the failures identified. At this stage, the casesof the failures can be mitigated to eliminate the failure, but first,they must be tested based on their respective consequences on thepatient and the facility. Therefore, the last pre-step of listing theresults of the medical process is applied to verify the magnitude ofthe failure to enable the hospital to decide whether to proceed withthe process or mitigate the possible causes of the failure.
Onceall the pre-steps above have been evaluated, the actual FMEA isprepared. Similarly, the preparation of the actual FMEA followsprecise steps the steps include severity, occurrence and thedetection (Ford et al., 2014). In the occurrence step, an analysisis conducted to estimate the probability of the existence of thefailures. In this step, the different causes of the failures areaccessed to determine the chances of happening. In other words, thehospital evaluates the probability of the occurrence of the reasonsfor the failure, which in turn reveals the likelihood of the failuresoccurrence. The probability of occurrence is gauged on a numericalscale and recorded.
Inthe second step, the severity of the failure, in case they occur, isestimated. Severity is the extent of the damage or the consequencesof the failure. In the scenario provided, the hospital has the dutyto analyze the seriousness of the possible failures that may occurduring the medical process. For instance, the therapeutic failure inthe case resulted in brain death and final death of the patient,which according to the severity analysis, would have been detected bythe ED physicians. The information gathered regarding the severity ofthe failure, influences the quality of service delivery, resourceallocation, attention offered and even possible transfer of thepatient to a better facility (Franklin et al., 2012). In other words,when severity is graded on a numeric scale and detected to be high,the facility has options of avoiding or transferring the subject orseeking better procedures.
Thefinal stage is the detection this is the probability of detectingthe possible failures and their causes in a process. It is advisablethat in every process, the potential failures should be detectable todesign the right course of action that may eliminate those failures.If the possible failures cannot be detected, the process is regardedas dangerous, and thus, further analysis and consultation areadvisable. In the scenario provided, the emergency nurses could notdetect the possible dangers of the numerous injections administeredto achieve skeletal muscle relaxation. Therefore, a process whosefailures are not detectable is hard to mitigate and should not beundertaken without further clarification. Once all the numericalvalues of severity, occurrence, and detection have been evaluated, aproduct known as Risk Priority Number (RPN) is calculated as thefinal determinant of the process.
Testingthe effectiveness of the improvement plan is crucial as it confirmsthe viability of the recommended changes. Measuring the efficiency ofthe improvement plan takes five methods. The first approach isregulatory inspection, whereby the provisions for improvements areinspected against the standards provided by the regulator. In thescenario, the improvement plan can be examined against the standardsof the Joint Commission, to test whether the adjustments conform tothe criteria, which are believed to be effective. Additionally, asurvey can be conducted on the customers or stakeholders to estimatetheir perception and response to the improvement plan (Franklin etal., 2012). In the hospital case, an improvement plan is measured bysurveying the patients` response to the new plans that is, the EDcould inspect the recovery rate of patients who undergo the improvedprocesses.
Testingthe effectiveness of the improvement plans is also conducted throughthird-party assessment and benchmarking. In this method, the elementsof the change program are assessed by another professional from ahigher level facility and with an exceptional experience. Similarly,the plan is benchmarked through comparison with the processes in ahigher-level hospital or past findings (Ford et al., 2014).Additionally, statistical indicators can be applied to analyze thenumerical data of the new plan. In the hospital scenario, thenumerical scale of the detection, severity, and occurrence areanalyzed through statistical theories and methods to test the impactof enacting the improvement plan. Finally, the organization canundertake internal assessment, whereby a team of internal experts istasked with the research to test the effectiveness of the improvementplan.
Inthe process of eliminating failures through the improvement plan,various stakeholders must play their roles adequately to achieve thequality assurance. In the scenario, the nurses have the greatestresponsibility for leading the quality assurance process their rolesare beyond just taking care of the patients. First, the nurses areresponsible for the proper assessment of the patient situation todetect the actual condition. It is the roles of hospital`s physiciansto conduct proper diagnosis to unveil all the elements of the patientsickness and avoid confusions or overdose of medication. Secondly, itis the roles of nurses to analyze the treatment process of everypatient and detect the possible failures of the medication. On thesame note, they should also evaluate the consequences of thepotential failures of the medical process and report the matter tothe relevant authorities immediately (Franklin et al., 2012). Thenurses are also responsible for a regular check-up of the patients toassess their response to the medication. For instance, in the caseprovided, Mr. B was not properly monitored by trained nursesinstead, they delegated their duty to the unskilled son of thepatient. Besides, they are also responsible for offering constantcommunication to the authorities and other departments to enhance theservice delivery to the patients.
Conclusively,Healthcare organizations are open to unanticipated sentinel eventsthat may have significant adverse impacts on the patient and thefacility. Consequently, it is advisable for the hospital to undertakeFailure Modes and Evaluation Analysis (FMEA) to help establish aneffective improvement plan and reduce the failures. FMEA preparationrequires precise steps discussed above, to ensure that the process isfully assessed and the possible failures detected. Similarly, theimprovement plan must be tested to ensure its effectiveness andfurther failures that may occur. Besides, the relevant stakeholderssuch as physicians must undertake their key responsibilities toreduce the failures, as well as participating in the FMEA.
Burke,W. W. (2013). Organizationchange: Theory and practice.Sage Publications.
Ford,E. C., Smith, K., Terezakis, S., Croog, V., Gollamudi, S., Gage, I.,… & Sibley, G. (2014). A streamlined failure mode and effectsanalysis. Medicalphysics,41(6).
Franklin,B. D., Shebl, N. A., & Barber, N. (2012). Failure mode andeffects analysis: too little for too much?. BMJquality & safety,21(7),607-611.
No related posts.