Project #72725 - Reword Essay (different from previous essay)

Just need this essay re-worded / paraphrased so it can be turned in and pass originality software. Thanks!

The purpose of this paper is to analyze the unfortunate sentinel event of Mr. B, a sixty-seven-year-old patient presenting with severe left leg pain at the emergency room.  A root cause analysis is necessary to investigate the causative factors that led to the sentinel event.  The errors or hazards in care in the Mr. B scenario will be identified.  Change theory will be utilized to develop an appropriate improvement plan to decrease the likelihood of a reoccurrence of the outcome of the Mr. B scenario.  A Failure Modes and Effects Analysis (FMEA) will be used to project the likelihood that the suggested improvement plan would not fail.  Lastly, key roles nurses would play in improving the quality of care in the Mr. B scenario will be discussed.
A. Root Cause Analysis
A root cause analysis (RCA) is “a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event” (Cherry & Jacob, 2011, p. 442).  The participants during the root cause analysis would be the emergency room physician (Dr. T.), the Mr. B’s LPN and RN (Nurse J) during the time of the sentinel event, the emergency room nurse manager, and the chief nursing officer (CNO) of the hospital.  These members would meet in a root cause analysis meeting to discuss the causative factors that created Mr. B’s sentinel event.  The first step in a root cause analysis on the sentinel event that caused Mr. B’s death is to gather the data surrounding the situation.  Mr. B’s vital signs, including his blood pressures, important laboratory values, pain scores, and history of medication dispensed during the situation must be collected.  The second step in a RCA is to describe the facts of Mr. B’s sentinel event.  The third step in a RCA on Mr. B’s sentinel event is to ask why each of the causative factors that led to Mr. B’s death occurred.  The causative factors that led to Mr. B’s sentinel event are Mr. B’s tolerance to opiates not considered, Mr. B.’s clinical situation not considered (i.e., Mr. B’s age and renal function), and knowledge deficit of opiates.  Drilling down the data to identify the root cause of Mr. B’s death is the fifth step in conducting a RCA on Mr. B’s sentinel event.  Upon analyzing the data, causative factors, and events leading to Mr. B’s sentinel event, the RCA team determined that the root cause of Mr. B’s death is a medication error.  Mr. B was given an overdose of hydromorphone.  The final step in a root cause analysis is to implement changes that will mitigate the root cause.  Changes include educating the nursing staff about hydromorphone, such as side effects and adverse reactions,    
A1. Errors or Hazards
There are errors and hazards in care that occurred in the Mr. B scenario.  One error was the emergency room physician’s failure to recognize the signs and symptoms of deep vein thrombosis (DVT) that Mr. B was presenting.  If not treated early, a DVT can become a pulmonary embolism, a fatal condition that Mr. B unfortunately developed.  Another error in care that happened in the Mr. B scenario is the nurses’ failure to monitor Mr. B’s ECG and respirations.  Early detection of critical ECG and respiratory changes could have initiated medical interventions that would have saved Mr. B’s life.  One hazard is the emergency room nurses’ heavy patient load at the time of Mr. B’s sentinel event.  Another hazard is having a licensed practical nurse (LPN), which is a liability to the nurse in the fast-paced, highly-critical emergency room environment.  One pertinent error is overdosing Mr. B with hydromorphone.  Mr. B was given a total dosage of 4 milligrams of hydromorphone within five minutes.  Hydromorphone is a highly potent opiate that must be carefully monitored for severe respiratory depression.
B. Improvement Plan
An improvement plan, stemming from change theory, must be in place in order to decrease the likelihood of a reoccurrence of the outcome of the Mr. B scenario.  The change theory utilized in this scenario would be the Associates in Process Improvement’s Model for Improvement.  The first half of the model has three fundamental questions:
1. Aim: What are we trying to accomplish?
  2. Measures: How will we know a change is an improvement?
3. Changes: What change can we make that will result in improvement?
(Lloyd, 2009)
The second half of the Model for Improvement is the testing phase developed by Walter Shewhart called the PDSA cycle, which stands for Plan, Do, Study, Act.  This four-step cycle is a simple mechanism to quickly test and tweak changes made in the process.  Let us apply the Model for Improvement to Mr. B’s scenario.  The aim of the improvement plan is to quickly screen for deep vein thrombosis in emergency room patients.  Measures include performing a D-Dimer blood test, a diagnostic test that determines the probability of a patient having deep vein thrombosis.  Another measure is to implement a flowchart detailing the signs and symptoms of deep vein thrombosis.  Every patient entering the emergency room complaining of any extremity pain would automatically be screened for deep vein thrombosis using the flowchart.  These changes would be improvements when there will be no reoccurrence of another Mr. B fatal event.  The PDSA cycle would then be in place to test and tweak the new deep vein thrombosis screening process.
C. Failure Modes and Effects Analysis (FMEA)
Failure Modes and Effects Analysis (FMEA) is a “systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change” (Institute for Healthcare Improvement [IHI], 2013, p. 1).    The goal of the Failure Modes and Effects Analysis is to increase the likelihood that the process improvement plan suggested would not fail.  The first step of a FMEA is to analyze the process by identifying the process flow. The FMEA in this scenario would be on the new hydromorphone monitoring process.  The second step of a Failure Modes and Effects Analysis is to evaluate each step of the hydromorphone monitoring process to see what could go wrong.  These are called “failure modes” (IHI, 2013, p. 1).  The failure modes in this scenario are the wrong dosage of hydromorphone and improper patient cardiac and pulse oxygenation monitoring while given hydromorphone.  For each of the failure modes, a ranking scale is used to determine the likelihood that harm will occur if anything went wrong (severity), the likelihood that what went wrong would occur (occurrence), and the likelihood that what went wrong was detected (detection).  The final step of a FMEA is to identify interventions to improve patient safety and to reduce to probability of a reoccurrence of Mr. B’s unfortunate death.
C1. Interventions
By changing the process of care, interventions are necessary to improve care in a similar situation as the Mr. B scenario.  One intervention would be to establish a clinical pharmacy program focusing on hydromorphone administration.  Another intervention would be to initiate a standard pain assessment and reassessment protocol.  The nursing and medical staff would be educated on how to manage pain in a patient like Mr. B with pain scores that never drops below five, despite increasing doses of hydromorphone.  Another intervention would be to have a standard hydromorphone order set with monitoring guidelines that emergency room doctors like Dr. T could use.  The testing of these interventions would occur for three months in the emergency room.  Medical records of emergency room patients that were given hydromorphone would be examined during the trial period.  Hopefully, the implementation of these interventions during the testing period would prevent the reoccurrence of Mr. B’s sentinel event.
C2. Pre-Steps
There are pre-steps in preparation for the FMEA.  First, select a process, preferably not a complex process such as medication management, but a smaller subset of a complex process.  In this case, a process for hydromorphone monitoring.  Second, assemble a multidisciplinary team to outline in detail the new hydromorphone monitoring process.  The multidisciplinary team could also list anything that could wrong with the new process and the corresponding causes.
C3. Three Steps
There are three steps of the Failure Modes and Effects Analysis: severity, occurrence, and detection.  Severity is the likelihood that harm will occur if anything went wrong.  If the wrong hydromorphone dosage and the improper patient cardiac and pulse oxygenation monitoring occur, how likely are those failures will occur?  Occurrence is the likelihood that what went wrong would occur.  How likely are the wrong hydromorphone dosage and the improper patient cardiac and pulse oxygenation monitoring while given hydromorphone would occur?  Detection is the likelihood that what went wrong was detected.  If the wrong hydromorphone dosage and the improper patient cardiac and pulse oxygenation monitoring occur, how likely are those failures will be detected?  Evaluation of the three steps is the final piece of the FMEA.
D. Key Role of Nurses
There are key roles nurses would play in improving the quality of care in the Mr. B situation.  Provision 2 of the American Nurses Association Code of Ethics is another provision that impacts my nursing practice. The provision states “The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient” (ANA, 2001, p. 1).  In order to avoid a reoccurrence of the Mr. B sentinel event, the emergency room nurses must be more vigilant of recognizing the early signs and symptoms of critical illnesses that could create sentinel events.  Nurses in the emergency room must also continuously monitor for ECG and respiratory changes that could potentially lead to sentinel events.
Conclusion
In conclusion, I investigated the causative factors leading to the sentinel event of Mr. B through a root cause analysis.  A Failure Modes and Effects Analysis created an improvement plan that decreases the likelihood of the Mr. B sentinel event from reoccurring was thoroughly examined.  Nurses would play key roles in improving the quality of care in the Mr. B situation.

Subject Medicine
Due By (Pacific Time) 06/03/2015 12:00 am
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