In response to at least two of your peers, answer the following: How would the quality initiative in the research report change if it had used the tracer

Eky Discussion:

The problem of the pediatric study was that the patient had notified the RN about his hand hurts, but the RN dismissed the concern and told him it is related to the IV running. Farther on the investigation, the RN did not follow procedure protocol and place the IV in the wrong part of Liam’s hand. The RN did saw a hard stop notification of in Liam’s chart, but also dismissed it. The RN did reach out for a physician to do a consult on the wound of the IV site, but the physician was not able to perform the consult until 6 hours later.

RCA problem solving framework was selected because an incident occurred while being cared by a medical professional. “RCAs are used to determine why an unexpected or unintended outcome occurred” (Haney, 2020, pg. 26). The RCA team had to investigate if this was an organizational error than an individual error. The RCA reviewed the communication, fatigue scheduling, equipment/environment, and the organizational rules, policies and procedure and if there were any barriers that contributed to the error.

The team members who are involved in the different steps of the problem-solving framework includes “various members of leadership, including representative from Quality, Risk Management, Nursing, and ancillary department and anyone in the care team that understand the process if IV extravasation” (Haney, 2020, pg. 27). The team members of those who are unbiases to evaluate the situation and understand the root cause of Liam’s incident.

The root cause analysis is a problem-solving framework to help improve quality of care. Its goal is to improve an undesired outcome or near miss incident that occurred in the healthcare organization. The RCA was able to identify the root cause of the error. Yes, the RN placed the IV in the wrong part of the patient’s arm, but the RN also dismissed the warning hard stop in the patient chart. This caused necrosis on Liam’s right hand. RN did seek a consult from a physician, but it took up to 6 hours for the consult. The RN did not follow the organization policy of checking in the IV every 2 hours and did the training that the hospital provided. Many factors had contributed to Liam lost the ability to use his dominate hand. The RCA was able to find a conclusion to prevent similar incidents. The is a reactive approach because the RN and physicians fail to follow procedures and protocols.

I agree with this selection because the RCA team was able to create an action plan to reduce risk of patients. This includes “periodically evaluating and analyzing the effectiveness of the RCA, and scheduling random audits” (Haney, 2020, pg. 29).

Reference:

Haney, K. (2020). Root Cause Analysis: A Pediatric Case Study.  Journal of Legal Nurse Consulting,  31(4), 26–29. Retrieved on November 12, 2024. Retrieved from  https://content.ebscohost.com/cds/retrieve?content=AQICAHiylJ_bvOB56hI8UzTN6Ryruh7a0kiIBN_ANwtaWYjmxwH47H71QF0qZZQHwO8VfGEWAAAA2DCB1QYJKoZIhvcNAQcGoIHHMIHEAgEAMIG-BgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDDWuISMtyz4bmOa58QIBEICBkAcAyTFEkMmga0YdP6Ega5oqqxjXf9GsWQ9xPBBjwWdMWeF8hpFSF7HvJ7Gz5SvBYrrO9OgBKxxfTsdUrFLGb69FlIHZKe6mkqXw5Outg_5Zg6vezwnLAoyhXqcCysY-5ZPG09nzHDc5QELjOj7V6yg4KEPJZwCduAEY-QeFos2eOu8-dqE6xq176bdd8e2e2g== 

Matthew Discussion:

Plan, Problem and Framework 

The PDSA framework was applied to guide implementation of a unit-based quality improvement (QI) project aimed at improving nutritional practices for neonates with critical congenital heart disease (CCHD) after complex surgery. The identified problem for this situation is during comparison of CCHD neonates’ discharge weight to their birth anthropometric measurements, no changes in growth or weight gain during hospitalization ensue (Newcombe & Fry-Bowers, 2018).

The PDSA framework was chosen in this situation because it has been widely tested and evaluated in healthcare and considered reliable/valid (Taylor et al., 2014; Varkey & Resar, 2007), but also because there is no published evidence-based literature pertaining to feeding guidelines for use with neonates with CCHD (Newcombe & Fry-Bowers, 2018); thus, numerous supplementation and feeding techniques alongside team functions needing periodic revision for program success (reduction in neonate malnutrition rate). Because administrative, clinical and nutritional functions are involved, a root cause to neonate malnutrition in this particular setting is not straightforward and required a new set of guidelines and systems through pilot interventions, studying outcomes and revisions to plans consistent and in alignment with PDSA cycles.

  Team members and contribution

A project champion (pediatric cardiothoracic surgery nurse practitioner) created a team consisting of 25 members from a cardiac surgeon, pediatric intensivists, a neonatologist, pediatric gastroenterologist, dieticians to occupation therapists, milk room staff, speech therapists and bedside nurses and nursing directors. Nurses input was used in feeding processes phases of planning including providing their perceptions on nutrition priority in the organization and whether education or training has ever been provided in a CTICU environment. Physicians’ expertise was used in steps associated with eternal nutrition ordering, gaps in knowledge of unique CCHD neonate needs and calculating specific/measurable caloric goals. A dietician’s expertise was used to establish nutrition recommendations and integrate them into physician ordering. Milk room staff input was attained to figure out barriers related to milk/formula order processing, delays etc. The nurse champion oversaw each phase of program implementation to ensure education to staff was provided, strategy modification, promotional material was developed and also peer-to-peer accountability and staff resistant to change were identified. All roles provided program planning insight depending on field of expertise and mutual involvement with the CTICU while department nurses were trained on new protocols and implemented these for 7 months during the “Do”. “Study” phases involved the nurse champion collecting quantitative data, benchmarking metrics of interest such as length of stay and qualitative data/analysis or creating an anonymous questionnaire for nurses involved in program implementation probing for compliance, usefulness, and protocol information ease of understanding. During the “Act” phase, the nurse champion revised protocol and program resources based on questionnaire feedback which required occupational/speech therapists’ input because feeding revisions were suggested.

Role of the PDSA Framework in research/conclusions

From this study, each phase of the PDSA framework perpetually evolved based on neonate medical, safety and nutritional needs. The multifaceted nature of neonate malnutrition created a complex problem with no one-way approach to manage and deliver CCHD nutrition and required constant assessment and revision to create new systems, create training resources, change EHR documentation procedures and program promotions. The PDSA framework played an effective role in revealing new evidence on feeding practices of CCHD neonates and positive outcomes were reported. This study indicated many barriers being process-related, specifically those involving nurse feeding administration steps clarification, so multiple revisions to the plan ensued before a standardized, best practice was permanently adopted. Since CCHD neonate nutritional and medical needs exhibit extreme variance from one another, new obstacles required constant changes which were initiated by the project champion/sponsor. I agree with applying the PDSA cycles because the lack of evidence-based literature on the topic compelled the project team to take on a trial/error methodology, and tailored solutions to each unplanned feeding and medical barrier was established with guidance from the appropriate clinical professionals.  

References

Newcombe, J., & Fry-Bowers, E. (2018). Improving Postoperative Neonatal Nutritional Practices in an Intensive Care Unit Using the PDSA Cycle.  Journal of Pediatric Health Care,  32(5), 426–434.

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