For this discussion forum, your initial posting? will be a root cause analysis (RCA) that includes an overview of the sentinel event, a fishbone diagram, and the five Why’s associated with
Discussion 5
For this discussion forum, your initial posting will be a root cause analysis (RCA) that includes an overview of the sentinel event, a fishbone diagram, and the five Why's associated with one of your possible root causes in the fishbone diagram. Your RCA will be based on one of the scenarios provided under "Materials," "Course Assignments." In your discussion group, please ensure that both scenarios are analyzed.
In this discussion, you will propose a solution to one of the possible root causes discovered in your fishbone diagram. Provide an in depth discussion of your proposed solution to the quality/safety issue using the PDSA/PDCA process. Be specific about what you would recommend to the organization to prevent the sentinel event from happening again in the future.
Provide feedback to two others regarding their root cause identification. Did all of you identify the same root cause? Why or why not?
MINNESOTA STATE UNIVERSITY, MANKATO
SCHOOL OF NURSING
NURS 420 Informatics, Quality, and Safety for RNs
Instructions: Review the Case Scenarios posted under “Course Content.” Also review the QI document by Health Quality Ontario posted under “Additional Course Readings.” Write a response using the following rubric as your guide to content required.
Criteria for Informatics, Safety, and Quality Research Paper
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Criteria |
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Introduction and Background: Select one of the scenarios in which a medical error(s) occurred. The scenarios are listed under “Content.” For the selected scenario, identify the problem and the significance of the issue in nursing and health care. Provide background information on the scenario, and explain the purpose of a Root Cause Analysis . |
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Fishbone Diagram: Develop a fishbone diagram that addresses the defects or problems you identified in the case scenario. You are expected to post a fishbone diagram that shows the defects by category as a part of the initial posting. Then, discuss the following: What might be the problems that led to the error? What are five why questions that you might ask to get more information related to the incident? Identify what you determine to be the top cause of the error. |
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Select one of the possible causes identified in the fishbone diagram. Write a 5 Whys for this cause.You do not need to select the identified root cause of the sentinel event. The 5 Whys can be written on any of the possible causes identified in the case scenario. |
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Summary: Tie together the sections of the posting. Include the major findings and conclusions drawn from the exercise. |
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The patient was a 67-year-old male who underwent a right total knee replacement. Following the procedure, the patient was treated in the post-anesthesia care unit where an epidural catheter was inserted for postoperative pain
management. Following one episode of hypotension, which was treated successfully with ephedrine, the patient was discharged to an inpatient medical-surgical care nursing unit with the epidural in place.
Approximately 3 hours after arriving on the unit, the patient was unable to tolerate ordered respiratory therapy due to nausea and vomited shortly thereafter. According to the nurse, approximately 10 minutes after the episode of vomiting, the LPN found the patient cyanotic and unresponsive and immediately called a code.
The nurse responded, as did the code team, and the patient was intubated and transferred to ICU. This account of events was disputed by the LPN and two other staff on the unit who understood that the nurse was responsible for the direct care of the patient. The LPN stated that it was the nurse who found the patient to be unresponsive at some point after the episode of vomiting and called the code herself. The elapsed time between the episode of vomiting and the code is also disputed.
The eventual diagnosis was anoxic encephalopathy due to the time that elapsed before CPR was initiated. The prognosis was poor and life support was withdrawn. The patient breathed independently and was transferred to hospice care where he subsequently expired.
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Carla is a 29-year-old woman with renal failure from polycystic kidney disorder, a congenital disease that requires her to undergo frequent dialysis. For several years, she has lived in a suburb of a medium-sized city in the American southwest. Carla is single and works part-time at a small printing company. Her boss offers her the flexibility to get to her dialysis appointments — which last three hours if the center is running on time — but the time away from work is a strain for Carla and for her boss.
It isn’t easy for Carla to get to her dialysis appointments three times a week. She recently had to give up her car because she could no longer afford car payments and insurance, so she now relies on buses and cabs to get to the dialysis center. Carla’s mother lives nearby and is a major source of emotional support; she gives Carla rides if she’s able to get time off work, but that is rarely possible. Carla has a few close friends who provide her with a strong social network, but because Carla’s appointments take so long and happen during business hours on weekdays, she usually has to go by herself.
Day One, Monday
In her arm Carla has an arteriovenous fistula, a surgically created connection between an artery and a vein, for hemodialysis. One Monday during dialysis at her usual outpatient dialysis center (a private center in a large chain of dialysis units throughout the area), the technician notes poor blood flow through the catheter. With poor flow, it is difficult, if not impossible, to complete an effective dialysis session. Because of the poor flow, it takes five hours to complete the dialysis that day, instead of the usual three. The nephrologist, Jesse, orders an ultrasound of Carla’s upper arm, to be done at the local hospital about eight miles away. The nurse, Mercedes, gives Carla a handwritten order form for the ultrasound and calls the radiology department, scheduling the test for 9 AM the next morning.
Carla is too embarrassed to tell Mercedes that she no longer has a car and may not be able to get to the test on time.
Day Two, Tuesday
Carla takes three buses in the morning, only to arrive at the hospital at 9:30 AM due to the complex bus schedule. When she checks in at the desk, the clerk, Jonas, tells her they cannot perform the test. He says the department has a policy that anyone who is more than 15 minutes late must be rescheduled. The department has a high percentage of patients who show up late or not at all, he says, and they want to be fair to those who arrive on time. Carla asks if there is any way to get the test done today, but Jonas, who got yelled at last week for sneaking in a late patient, tells her this is simply not possible. He reschedules the test for Thursday at 10 AM. Upset, frustrated, and exhausted by the fact that she just wasted several hours, Carla goes home.
Day Three, Wednesday
Wednesday morning Carla goes to dialysis as usual. This time, there is almost no blood flow through her fistula. Jesse, the nephrologist, orders a blood test of, among other things, her potassium level, to make sure dialysis is still regulating Carla’s electrolytes. She is sent to the emergency department (ED) after the potassium check comes back dangerously high at 6.3 mmol/L. The care team in the ED treats Carla’s potassium level with a combination of medications. An ultrasound, the same type of procedure that Jesse ordered on Monday, shows a significant blood clot within Carla’s fistula that extends into her vein.
Carla is admitted to the hospital and given tPA (tissue plasminogen activator) to break up the clot — an effort that is successful. Afterward, Rachel, the internal medicine resident caring for Carla, starts her on intravenous heparin and oral warfarin (both blood thinners) to prevent the clot from recurring. A temporary dialysis catheter is placed in Carla’s neck, and that night she has dialysis that corrects her high potassium level.
Day Seven, Sunday
On Sunday, Carla is ready for discharge. Lydia, the nurse caring for her that day, goes over the written discharge instructions with her. Lydia tells Carla to see her primary care physician by Tuesday to have her International Normalized Ratio (INR) checked, since she is taking warfarin.
Lydia says that after this initial check on Tuesday, Carla’s primary care physician will need to check her INR on a weekly basis. The goal, Lydia says, is for Carla’s INR level to be between 2 and 3 (therapeutic) to keep the risk of clotting low, but the level can fluctuate significantly over time, so it’s important to make sure it’s checked regularly. Carla shakes her head and tells Lydia that it’ll be hard to get to her primary care doctor so her INR levels can be checked — it’s just too much for her to do on top of dialysis.
Quickly, Lydia finds Ana, the social worker on the unit, and asks about an alternate plan for Carla. The two of them decide that the dialysis unit might be the best place to check her INR in the future, since she goes there anyway three times a week. Ana informs Lydia that many dialysis units follow INR levels for patients, so this seems reasonable. Ana also suggests that Carla meet with a nutritionist before she leaves. The reason is that there are many foods that contain vitamin K, which counteracts the effects of warfarin. It would be a good idea for Carla to learn which foods she should avoid after her discharge. Lydia thinks this is a good idea and decides to contact a nutritionist. However, it’s Sunday, and no nutritionist is available. Lydia asks the physician filling out Carla’s discharge orders to request an outpatient nutrition appointment instead.
All these instructions are written on Carla’s discharge orders. Tired from poor sleep over the past few days in the hospital, Carla barely remembers hearing the instructions and leaves the written discharge instructions in her friend’s car when she goes home. A discharge summary is mailed to her primary care doctor; this is the typical mechanism for communication from the hospital to outside physicians.
The hospital’s appointments desk (open Monday through Friday) makes a nutrition appointment for Carla the day after her discharge, but when the case worker calls Carla, her phone is disconnected. The case worker mails her an appointment slip instead, but it is unclear whether or not she receives it. She does not come to the appointment.
Day 25, Thursday
Two and a half weeks later, a friend brings Carla to the emergency department. Carla has right arm pain and swelling. Studies show she has a new deep venous thrombosis (a blood clot in a vein deep in the body), and her INR is 1.1. When asked about her warfarin dosage, she says nobody has been checking it, and that she has been taking the 2.5 mg per day warfarin dose she was discharged on two weeks ago. She says she was aware that her INR was supposed to be checked at the dialysis unit, but that when she went for dialysis, this didn’t happen. She says she brought it up with the medical assistant who took her weight and blood pressure at the start of her visit to the dialysis unit. The assistant told Carla that he didn’t know about the INR issue but would check on it. Carla says she never heard anything more about it.
Once again, Carla is admitted to the general medicine unit and placed on an intravenous heparin drip and oral warfarin. It takes 10 days for her INR to creep up to therapeutic range. She has significant pain in her right arm, and she now requires intermittent oral narcotics to function. Ana, the same social worker from the last hospitalization, calls Carla’s dialysis unit and speaks to the nurse manager about following the INR. Ana feels horrible about the communication lapse at the end of Carla’s last hospitalization. The resident calls Jesse, Carla’s nephrologist, to make sure he too is aware he needs to follow her INR levels closely, and that they will be drawn during dialysis each week.
During this hospitalization, Carla is finally able to meet with Jane, the nutritionist. It turns out that Carla has been intermittently eating spinach salads as part of a weight loss diet she is on. Spinach has large amounts of vitamin K and counteracts warfarin. These salads may well have been making her anticoagulation levels unstable. Jane gives Carla some written information about which foods she can eat as well as the importance of eating approximately the same amounts every day.
Day 36, Monday
Carla goes home late on Monday, after dialysis in the hospital. She spent her 30th birthday in the hospital. Because of visiting restrictions, her mother and friends had to leave at 8 PM rather than staying a few more hours to spend time with her.
At home Carla feels nauseated and ends up vomiting. She skips her dialysis run on Wednesday, feeling too worn out and sick to go. Mercedes, the nurse at the dialysis center, is surprised when Carla doesn’t show up. She calls Carla’s cell phone, but she only gets a message that the number has been disconnected. Mercedes considers calling the police to have them check on Carla. One of her patients has a sudden drop in blood pressure during dialysis, however, and in her rush to help, she forgets to make the call.
Later that day Carla realizes that her face is tingling. Her friend, the same one who took her to the ED the last time, urges her to call someone, but Carla just wants to try and get some sleep. She feels exhausted and sick.
Concerned when the tingling is worse on Thursday morning, Carla decides her friend was right, and she goes back to the emergency department. She arrives at the ED at 1 pm, but she has to wait two hours before labs are drawn. The physician sees her, writing in her chart that her neurologic exam was “non-focal.” This wording is sometimes used when a physician completes only a cursory exam.
Carla’s potassium levels are the first lab results to show up. (Typically, the lab is able to process potassium levels more quickly than INR levels, because of the way the tests are done.) Her potassium is again high at 6.7 mmol/L. Because this is considered by the hospital to be a “critical value,” the lab technician calls the ED and promptly relates this potentially life-threatening result to the ED nurse, who tells the ED physician. The physician pages the nephrology fellow, who gets Carla sent over to dialysis immediately. Carla’s other lab results, including her INR levels, show up about 30 minutes later. Her INR is 5.3. A lab technician enters the result into the computer.
At about 6 PM, Carla arrives on the medical surgical unit in the hospital. Fatigued, she again complains of face tingling and nausea. She is given some compazine for the nausea (there is a standing order for compazine as needed) and falls asleep.
Day 40, Friday
Early the next morning, Grant, a medical student, sees Carla. He thinks she seems overly tired but does not really know her baseline mental status. Grant decides to wait until formal patient care rounds to voice his concerns. During rounds at 9 AM, he speaks to Valerie, the attending physician. Valerie looks up Carla’s lab results on the computer and notes the extremely high INR. She orders an emergency CT scan of Carla’s head.
Ninety minutes later the radiologist pages Valerie. Carla has an acute subdural hematoma (a bleed on the brain). She is transferred to the intensive care unit, neurosurgery is called, and the care team gives Carla fresh frozen plasma to replace the clotting factors she no longer has in her blood. The surgeons take her to the operating room, remove the bulk of the hematoma and stop the bleeding.
Carla has a very slow recovery and is left with significant short-term memory deficits. Carla is no longer able to live on her own and after much effort by Ana, the social worker, she is admitted to a long-term care facility that can care for a 30-year-old woman with dialysis requirements. Carla will be the youngest resident in the long-term care facility.
About Carla’s health care system:
Carla receives her care from several systems, the largest of which is SouthWest Medical. SouthWest Medical owns three large hospitals in the metropolitan area, including one academic hospital that has residents and medical students. SouthWest Medical also owns 25 primary care clinics, including the one that Carla goes to, scattered throughout the area. SouthWest Medical uses an electronic medical record for the hospital, but the system is still in the process of rolling this out to the clinics. Twenty-one of the clinics, including Carla’s, still use a paper-based charting system. The dialysis centers are part of a private consortium and are not affiliated with SouthWest Medical. The dialysis centers employ their own staff and physicians, and they have their own electronic medical record that is not linked to that of SouthWest Medical.
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SECOND EDITION
Core Competencies for Nursing Leadership and Management
INTRODUCTION TO
QUALITY AND SAFETY EDUCATION
FOR NURSES
Editors
PATRICIA KELLY BETH A. VOTTERO CAROLYN A. CHRISTIE-MCAULIFFE
ISBN 978 ‑0‑8261 ‑2341‑1
11 W. 42nd Street New York, NY 10036-8002 www.springerpub.com
INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES Core Competencies for Nursing Leadership and Management, SECOND EDIT ION
Editors PATRICIA KELLY, MSN, RN BETH A. VOTTERO, PhD, RN, CNE CAROLYN A. CHRISTIE-MCAULIFFE, PhD, FNP
The second edition of Introduction to Quality and Safety Education for Nurses has been thoroughly updated with an emphasis on leadership and management. The content continues to focus on knowledge and skills required of entry-level nurses in the six Quality and Safety Education for Nurses (QSEN) domains. After heart disease and cancer, patient safety errors rank as the third-leading cause of death in the United States. As patients’ needs have increased in complexity and inter-professional teamwork and collaboration have become essential, only strong leadership skills can ensure high-quality and safe care. Nurses, the largest group of healthcare professionals that spend the most time with patients, are uniquely suited to lead through effective management and communication in this dynamic environment.
With contributions from nurses, physicians, pharmacists, librarians, attorneys, and other healthcare professionals throughout the United States and beyond, Introduction to Quality and Safety Education for Nurses, Second Edition underscores the inter-professional focus grounding healthcare practice today. The updated edition includes four new chapters on implementing quality and safety initiatives from a leadership and management perspective, and state-of-the-art information on quality improvement. Each chapter contains learning objectives, opening scenarios, case studies, interviews, critical thinking exercises, key concepts, clinical discussion points, review activities, NCLEX-style questions, and web resources.
New to the Second Edition:
• Increased focus on leadership and management aspects of quality and safety • Updated information from national and state healthcare and nursing organizations • An evolving clinical case study for application of concepts throughout the text • Additional patient care cases and real-life examples • Interviews with a myriad of healthcare professionals such as educators, library scientists, lawyers,
psychologists, risk managers, and many others • Four new chapters addressing nurse leadership and management of high-quality care, legal and ethical
aspects of quality and safety, delegating patient care and setting priorities, and quality improvement project management
Key Features:
• Helps nursing schools to fulfill accreditation standards for quality and safety curricula • Maps the QSEN competencies for knowledge, skills, and attitudes (KSAs) for each chapter • Includes objectives, critical thinking exercises, case studies, interviews, NCLEX-style questions, photos,
tables, suggested readings, and more in each chapter • Provides instructor package with PowerPoint slides, Q&A, answers for case study and critical thinking
exercises, and more • Provides knowledge for nursing education QSEN-specific courses • KSAs throughout chapters
K ELLY
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SECOND EDIT ION
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Kelly_9780826123411_mech.indd 1 6/19/18 9:39 AM
INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES
Patricia Kelly, MSN, RN, earned her diploma in nursing from St. Margaret Hospital School of Nursing, Hammond, Indiana; baccalaureate in nursing from DePaul University in Chicago, Illinois; and master’s degree in nursing from Loyola University in Chicago, Illinois. She is Professor Emeritus, Purdue University Northwest, Hammond, Indiana. She has worked as a staff nurse, travel nurse, school nurse, and nurse educator. Patricia has traveled extensively in the United States, Canada, and Puerto Rico, teaching at conferences
for the Joint Commission, Resource Applications, Pediatric Concepts, and Kaplan, Inc. She currently teaches nationwide National Council Licensure Examination for Registered Nurses® (NCLEX-RN®) review courses for Evolve Testing & Remediation/ Health Education Systems, Inc. (HESI), Houston, Texas. She also currently volunteers in a level one trauma center, emergency room, Advocate Christ Medical Center, Oak Lawn, Illinois and has been a nursing volunteer at the Old Irving Park Community Clinic in Chicago, a free clinic for patients without healthcare insurance.
Patricia was director of quality improvement at the University of Chicago Hospitals and Clinics. She has taught at Wesley-Passavant School of Nursing and Chicago State University. Patricia was program director of the Associate Degree Nursing Program and is Professor Emeritus, Purdue University Northwest, College of Nursing, Hammond, Indiana. Patricia has taught Fundamentals of Nursing, Adult Nursing, Nursing Leadership and Management, Nursing Issues, Nursing Trends, Quality Improvement, and Legal Aspects of Nursing. She has been a member of Sigma Theta Tau, the American Nurses Association, and the Emergency Nurses Association. She is listed in Who’s Who in American Nursing, Notable American Women, and the International Who’s Who of Professional and Business Women.
Patricia has served on the board of directors of Tri-City Mental Health Center, St. Anthony’s Home, and the Mosby Quality Connection. She is a coeditor/author of Introduction to Quality and Safety Education for Nurses, Core Competencies, first edi- tion, with coeditors/authors Beth A. Vottero and Carolyn Christie-McAuliffe. Patricia is also an editor/author of Nursing Leadership and Management, now in its third edi- tion in the United States and Canada; Essentials of Nursing Leadership and Management (with Janice Tazbir, coeditor/author), now in its third edition; and Nursing Delegation, Setting Priorities, and Making Patient Care Assignments (with Maureen Marthaler, coedi- tor/author), second edition. She contributed a chapter, “Preparing the Undergraduate Student and Faculty to Use Quality Improvement in Practice,” in Improving Quality, second edition, by Claire Gavin Meisenheimer. Patricia also contributed a chapter on Obstructive Lung Disease: Nursing Management in Contemporary Medical-Surgical Nursing by Rick Daniels. She has served as a national disaster volunteer for the American Red Cross and has also been a team member on healthcare relief trips to Nicaragua. Patricia has been a nurse for 50 years and currently lives in Chicago, Illinois, and in Fort Myers, Florida. She can be reached at [email protected]
Beth A. Vottero, PhD, RN, CNE, earned a baccalaureate degree in liberal studies with a focus in business management from the Uni- versity of Maine at Presque Isle; a baccalaureate degree in nursing from Valparaiso University; a master’s degree in nursing from Uni- versity of Phoenix; and a PhD in nursing education from Capella University. Previously, Beth taught in the undergraduate nursing at Purdue University North Central and the graduate nursing program at Bethel College. Beth currently is an associate professor of nursing
at Purdue University Northwest, teaching courses including Evidence-Based Practice and Knowledge Translation at the doctoral level and Informatics and courses in the
Nurse Educator program at the graduate level. At the undergraduate level, she teaches Quality and Safety for Professional Nursing Practice, Informatics, and Evidence-Based Quality Improvement projects in the Capstone course.
Beth’s background includes over 18 years as a staff and charge nurse. After com- pleting her doctorate, Beth coordinated and led a successful Magnet redesignation for Indiana University Health La Porte Hospital in La Porte, Indiana. She brought a desire to instill quality concepts to academia where she created an undergraduate quality course at Purdue Northwest focused on quality and safety in healthcare. Beth is a research associate with the Indiana Center for Evidence-Based Practice in Hammond, Indiana, a Joanna Briggs Institute (JBI) Collaborating Center. Through this associa- tion, she has completed systematic reviews on various topics. In collaboration with Dr. Lisa Hopp, she assisted in developing an Evidence Implementation Workshop to train nurses in translation science using an evidence-based quality improvement focus. Beth is a certified Comprehensive Systematic Review Program Trainer with JBI and conducts weeklong training for healthcare providers nationally.
Beth has published chapters in Hopp and Rittenmeyer’s Introduction to Evidence-Based Practice: A Practical Guide for Nurses; Bristol and Zerwekh’s Essentials of E-Learning for Nurse Educators; and has developed case studies for Zerwekh and Zerwekh’s Nursing Today: Transitions and Trends. She has published several articles on “Teaching Informatics” (Nurse Educator QSEN Supplement), “Conducting a Root Cause Analysis” (Nursing Education Perspectives), and “3D Simulation of Complex Health Care Environments” (Clinical Simulation in Nursing). Beth is an active member of the QSEN Academic Task Force with multisite studies on quality and safety education for nurses (QSEN) teaching strategies. As a funded researcher through Purdue University, Beth has studied factors affecting medication errors in the clinical setting. Beth can be reached at [email protected]
Carolyn A. Christie-McAuliffe, PhD, FNP, obtained her diploma in nursing from Crouse-Irving Memorial Hospital School of Nursing, Syracuse, New York; a baccalaureate and master’s degree in nurs- ing from the State University of New York, Health Science Center at Syracuse, Syracuse, New York; and a PhD in nursing from Bingham- ton University, Binghamton, New York. Her clinical experience has included staff nursing, home healthcare, oncology care, and private practice. She has functioned as an administrator primarily in clinical
research and taught at the undergraduate and graduate nursing levels at Crouse-Irving Memorial Hospital School of Nursing, Syracuse, New York; the College of Notre Dame of Maryland, Baltimore, Maryland; State University of New York (SUNY) Institute of Technology, Utica, New York; and Keuka College, Keuka Park, New York. She has implemented multiple evidence-based practice and
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