Root Cause Analysis and Failure Improvement Plan

The problem that occurred in this case scenario is the death of Mr. B, a patient who arrived in the hospital complaining of severe pain in the hip region and the left leg secondary to a fall. The death of the patient occurred following a series of intervention that took place prior to his transfer for advanced care in the tertiary facility. The patient sustained brain death during the intervention and hip reduction procedure. There are a series of event that occurred during the entire process that could have led to the brain death of Mr. B. First, a complete history of Mr. B was not taken prior to commencing the procedure of hip reduction. The history was important in understanding the treatment that the patient was on the probable effects that the drugs might have on the new drugs to be administered. The physician instructed the administration of diazepam and then hydromorphone without considering the possible drug interaction between the two sedative drugs and the opioid-oxycodone.

During the procedure of reduction, the patient was not put on any oxygen supplementation or ECG monitor. According to the conscious sedation policy of the hospital, every patient must be put on continuous blood pressure monitors, ECG and pulse oximeter throughout the procedure until the patient is declared stable. To some extent the policy was ignored because from the time the reduction procedure began up to the time the Ed team left for the respiratory distress patient, Mr. B was not on any monitor except the automatic blood pressure monitor and pulse oximeter. The patient was left under the watch of his son who had no medical background or any awareness of the changes in the vital signs. When the Mr. B’s son reported about the alarm ringing, the LPN noted the reduction of the oxygen saturation to 85% and instead of intervening; the LPN reset the alarm and did not report to the RN or the physician. The response team was only alerted after the blood pressure had seriously fallen and the oxygen saturation was far below normal.

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It can therefore be concluded that the series of events that took place prior to the transfer of Mr. B lead to his death. The use of large doses of sedative drugs, the lack of vital signs monitoring and poor intervention plans all contributed to the death of the patient. The brain death could have occurred due to excessive sedation or limited oxygen supply secondary to reduced blood pressure. The ventricular fibrillation occurred to the rapid heartbeats and tachycardia that occurred due to the compensatory response by the head to the seriously reduced blood pressure. The fact that the ED department only had one RN and one physician could also have contributed to the events that led to the death of the patient.

Process Improvement Plan

The improvement plan should begin with the change theory that can be employed in this situation which is the Lewin’s Change Management Theory. The theory tries to explain the human behaviors that relate to change and change resistance patterns (Sutherland, 2013). There are three stages in this model. Unfreezing, change and refreeze requires previous practices to be forgotten and redirected. The unfreezing stage of the theory enables organizations to understand the difficulties that relate to the problem identified and the strategies to be developed to achieve the process of change.  The first step in the model is to Unfreeze by debriefing the situation with all the staff to find out what they felt went wrong. Did they follow policies, did they take shortcuts etc. The second step is to change by increasing the number of staff in the emergency department from one RN to three or more and an additional physician and more LPNs. The staff should all obtain training on advanced trauma and cardiac life support and the conscious sedation module. Strict adherence to the hospital polices should be ensured to prevent the re-occurrence of the case where the conscious sedation policy was ignored during the procedure of hip reduction of Mr. B. By increasing the number of the RNs in the setting, the possibilities of having an inadequate history as in the scenario will be avoided and the patients will be monitored more closely as well as necessary interventions conducted in due cause.

The LPNs working in the setting should be more empowered and accorded necessary communication skills that enable them to report any problems promptly before anything worse happens.  The third and final step is to Refreeze and that would involve running a mock code or emergent situation to ensure the staff have let go of the old way of thinking and ensure they have adapted to the new policies. This would be followed with periodic in-services for re-education and refreshing of the policy. 

Failure Mode and Effects Analysis

The entire emergency department team including the nurses, doctors, laboratory technicians and other members will be involved in the FMEA. The steps that will be involved in the FMEA will include the identification of the probability of an event occurring, being aware of the possible severity of the event, detection, dormancy, indication and finally the risk level (Neal, 2013). Severity is the consequences of the failure mode set towards the improvement plan. To understand the consequences, an analysis can be conducted to identify any previous failures and the consequences. Detection involve the creation of awareness of the possibility of failure occurring and the steps to be undertaken. The occurrence step is applied when failure has occurred and the improvement plan is being implemented.

The professional nurse plays a very significant role as a leader in quality care promotion and influencing the activities of quality improvement (Needleman, 2009). The nurses contribute directly to quality improvement by communicating the area of the hospital that needs changes so as to achieve the desired quality. The nurses are more involved with the patients and they understand the conditions of the patient more and therefore they are aware of the level of adequacy of supplies and the requirements needed by the patients. The nurses are also in constant contact with the patient relatives who form the base of external stakeholders who possess a lot of information of the areas of the hospital that need change.


Neal, R. (2013). Modes of Failure Analysis Summary for the Nerva B-2 Reactor. Washington DC: Wiley Series.

Needleman, J. (2009). The Role Of Nurses In Improving Hospital Quality And Efficiency: Real-World Results. Health Affairs, 28(4), 625-644.

Sutherland, K. (2013). Applying Lewin’s Change Management Theory to the Implementation of Bar-Coded Medication Administration. Canadian Jounal of Nursing Informatics, 50-62.

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