Complete a root cause analysis (RCA) that takes into consideration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s outcome).

Additional information: The hospital where Mr. B. was originally seen and treated had a moderate sedation/analgesia (“conscious sedation”) policy that requires that the patient remains on continuous B/P, ECG, and pulse oximeter throughout the procedure and until the patient meets specific discharge criteria (i.e., fully awake, VSS, no N/V, and able to void). All practitioners who perform moderate sedation must first successfully complete the hospital’s moderate sedation training module. The training module includes drug selection as well as acceptable dose ranges. Additional (backup) staff was available on the day of the incident. Nurse J had completed the moderate sedation module. Nurse J had current ACLS certification and was an experienced critical care nurse. Nurse J’s prior annual clinical evaluations by the manager demonstrated that the nurse was “meeting requirements.” Nurse J did not have a history of negligent patient care. Sufficient equipment was available and in working order in the ED on this day.
Task:
A. Complete a root cause analysis (RCA) that takes into consideration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s outcome).
B. Discuss a process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario.
1. Discuss a change theory that could be used to implement the process improvement plan developed in B.
C. Use a failure mode and effects analysis (FMEA) to project the likelihood that the process improvement plan you suggest would not fail.
1. Identify the members of the interdisciplinary team who will be included in the FMEA.
2. Discuss steps for preparing for the FMEA.
3. Apply the three steps of the FMEA (severity, occurrence, and detection) to the process improvement plan created in part B.
4. Explain how you would test the interventions from the process improvement plan from part B to improve care in a similar situation.
Note:You are not expected to carry out the full FMEA, but you should explain each step, and how you would apply it to your process improvement plan.
D. Discuss how the professional nurse may function as a leader in promoting quality care and influencing quality improvement activities.
E. When you use sources to support ideas and elements in a paper or project, provide acknowledgement of source information for any content that is quoted, paraphrased or summarized. Acknowledgement of source information includes in-text citation noting specifically where in the submission the source is used and a corresponding reference, which includes:
• Author
• Date
• Title
• Location of information (e.g., publisher, journal, or website URL)
Note: The use of APA citation style is encouraged but is not required for this task. Evaluators will offer feedback on the acknowledgement of source information but not with regard to conformity with APA or other citation style.
Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from outside sources, even if cited correctly
Please include all parts see below:
Evaluation Method
A rubric is used in this Evaluation.
The candidate provides substantial articulation of response.
The candidate completes an appropriate root cause analysis (RCA), with substantial detail, that takes into consideration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s outcome).
The candidate provides a logical discussion, with substantial detail, of a process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario
The candidate provides a logical discussion, with substantial detail, of a change theory that could be used to implement the process improvement plan developed in B.
The candidate uses a failure mode and effects analysis, with substantial support, to project the likelihood that the process improvement plan suggested would not fail.
The candidate accurately identifies the members of the interdisciplinary team who will be included in the FMEA.
The candidate provides a logical discussion, with substantial detail, of the steps for preparing for the FMEA
The candidate appropriately applies, with substantial detail, the 3 steps of the FMEA (severity, occurrence, and detection) to the process improvement plan created in part B.
The candidate provides a logical explanation, with substantial support, of how the candidate would test the interventions from the process improvement plan from part B to improve care in a similar situation.
The candidate provides a logical discussion, with substantial detail, of how the professional nurse may function as a leader in promoting quality care and influencing quality improvement activities.
The candidate provides source information for all quoted, paraphrased and summarized content. Source information appears to include accurate and complete acknowledgement of source information regarding the author, date, title and location of the information (e.g., publisher, journal or website URL) as well as appropriate in-text citation. This level is also appropriate if there is no evidence of quoted, paraphrased or summarized content, and it is not required by the instructions.

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