OrganizationalSystems and Quality Leadership
Causeanalysis that led to the loss of Mr. B
Followinga close assessment of the scenario, several factors were in line forthe complications that arose in the patient. The core reason for theconditions that occurred in the client was caused by drug overdose.The patients had been prescribed other medicines for his underlyingconditions which were, atorvastatin used to take care of the lipidproblems and oxycodone that was primarily responsible for theantidepressant effect. The standard recommended dosage for diazepamin muscle spasm is 5-10 mg[ CITATION Bre13 l 1033 ],then a next similar dosage in a span of 3-4 hours. The mistake madefor Mr. B is that he was given a 7 mg of diazepam and 7mg ofhydromorphone in the span of only ten minutes (4:05pm-4:15 pm). Thedosage translates to an overdose which has negative clinicalmanifestations.
Althoughit has been rare to experience cases of diazepam overdoses resultingin death it has resulted in conditions such as coma, over sedationand reduced reflexes which were seen in Mr.B.Similarly, high dosesof hydromorphone have been found to cause breathing problems such aslabored and shallow breathing. Due to the effect of the difficultbreathing the hospital has identified counter measure where by oxygensupplementation is to be given to the patients prescribed withhydromorphone. Since the patient was not subjected to the requiredoxygen supplementation, he was, therefore, exposed to the developmentof coma, low blood pressure, and pinpoint pupils. Lack of oxygensupplementation resulted in the poor oxygen saturation levels thatlater led to heart failure and loss of palpable pulses.
Itis also evident that many erroneous events happened in the course ofthe deterioration of Mr.B health condition. The major errors are seenin the choice of drugs used for sedation, where the physician failsto consider the medical history of the patient before choosing anappropriate sedation agent. This negligence resulted in the wrongprescription that later led to over dosage. Secondly, the nurses failto identify the level of need of patients. Nurse J leaves Mr.B withmajor monitoring needs and rushes to discharge the other patientsforgetting to provide all the required equipment to Mr. B such as theoxygen supplementation tool.
Animprovement plans to cease recurrence of the above situation.
Mistakesare made and with the existence of these facilities in the society,delivery of health care must always be improved whatsoever. It,therefore, requires implementation of several policies in the healthsectors that would foster the provision of better services to theconsumers. I would encourage the integration of the Kaizen theorywhich looks into a continuous improvement to build Interventions thatwould revolve the provision health services a mile ahead from thecase seen in the scenario above. The plan gives the worker a chanceto use the mistakes to build on to a better status. It will beachieved through setting targets and practice of FMEA which are laidfor the employee to work towards their achievement.
Inthe interventional plan, includes planning where you need toidentify the opportunity for implementation of new system. It is thenfollowed by analysis of the results from the newer method and thesuccess of the plan is followed by a large scale adoption of theplan. It means patients would be attended to by the staffs accordingto their level of need. To identify a better plan, information fromthe worker has to be collected, when and why the defaults happenedshould be explained. The success of the selected improvementplan(Kaizen) relies on teamwork where both parties, the employer andemployee participates in systematic analyses and measuring processesto enhance accuracy and consequently, reduce variations and errors.
Theplan will also be obliged to ensure it meets the dynamism in thequality of services required. With the development of a continuousquality improvement model (CQI) and observation of automaticadaptation that would help to evaluate the positive variations andpositive deviances would assist in the service delivery. A Plan toStudy Act (PDSA) is another reinforcement under this theory thatwould facilitate the acquaintance of operational and literaturelearning skills for the health care providers to ensure they are wellequipped with the required knowledge to handle patients. Lastly,innovation and organization where a hierarchy of medical facilitywill be developed and enough medical workers employed to giveservices would ensure no recurrence of such scenarios occur[ CITATION Dav06 l 1033 ].
Assessmentof the improvement plans using the FMEA.
Membersto be included in the FMEA
Inthe establishment of a successful failure mode effect analysisprogram, then the participants are selected across all thedisciplines ranging from the many fields named below. It willinclude: consumers of the medical services, proprietors of medicalinstruments, human resource managers medical inspectors finally themedical service providers.
Stepsof preparing for FMEA
Seekindividuals with the proper knowledge about health care delivery. Itis preceded by pre-steps in which all components, functions andprocess that can fail are identified through testing and comparing tothe existing gaps health delivery. This is achieved through employeeinterview and assessment. I, therefore, decided to choose patients,health care providers and medical equipment and product suppliers andinspectors. Secondly, I determined the scope of my main theme whichis to improve service delivery. Next, I identified the possiblefailures. Fourthly, development of the scope and defined the functionof each in the service delivery. Following the features I came upwith, I recognized the ways in which the failures would occur.Consequences of the related failures were next on highlight and theseverity of each effect recorded. I found out the occurrenceprobability, for each cause and how to control them, came up withdetection techniques and calculated the probable chances of failure[ CITATION She09 l 1033 ].
Severalrisk factors arise, and they can knock my improvement plan back tothe flow if all the successful techniques are not implied. Forinstance, training enough health care facilitators is paramount butmeeting their wages with increased recruitment would be challenging.This would lead to low labor output and thus reduced servicedelivery. To effect this problem, we will develop a payment policywith qualification and the provision of services. Better wages wouldalso encourage more trainees to pursue nursing and medicine tofacilitate service delivery in this sector[ CITATION She09 l 1033 ].It, therefore, remains high that my improvement plan would bebreakthrough.
Thiswould be conducted by a questionnaire model and interviews involvingthe family members to the victims and the survivors of the servicesoffered by the health care facilities. Service providers will also beinterviewed, and the difficulties involved be expressed to ensurethat the improvement plan inclusively counters the situation.
Theimportance of the professional nurse.
Inthe medical sector, professionalism is treated as an importantcharacter since ethical consideration is paramount when handlinghuman life. Trained service providers are required in this industryto ensure that quality of service is improved. Professional nursesare always aware of the priority concerning the patient needs whichhelp to save lives. Negligence is avoided by qualified practitionersin the health sector by enacting the proper responsibilities andrights of the patients in their duties.
Also,they help in formulation and implementation of sound policies thatare very critical in the provision of health services. They conductsafe staffing practices, delegate tasks and promote clinicalpractices.
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MJ, B. (2013). The Effect of Opioid Therapy on Endocrine Function. The American Journal of Medicine, 12-18.
Shebl NA, F. B. (2009). Is Failure Mode and Effect Analysis Reliable? J Patient Saf, 86-94.