ESSAY: Root Cause Analysis and Failure Modes and Effects Analysis

Root Cause Analysis

            Root Cause Analysis (RCA) refers to an approach used to conduct a systematic search on an incident’s underlying causes to facilitate the identification and implementation of the most effective and viable solution (Fassett, 2011). The primary objective of carrying out an RCA is to avoid similar adverse incidents from reoccurring in the future.

RCA Steps

            The first step is to determine what happened, correctly and entirely. This step can only be successful if teams are formed, and a diagram incorporated to help with clarity. The second step involve idealizing the situation by determining what should have happened, instead. This step provides a controlled scenario where analysis of an ideal case is carried out to facilitate a better understanding of the extent of the situation. The third step is to determine the causal factors. For example, various factors are identified as major contributors to the problem. Experts or such diagrams as Ishikawa may be included in the process. The fourth step involves identifying the root cause of the problem, which means digging deeper on the issue using the causal factors, for leads. The fifth step comprises listing recommended actions to prevent the problem from reoccurring. The last step involves crafting a summary and sharing it among interested parties or shareholders.

Causative and Contributing Factors

            Mr. B had undergone heavy sedation with hydromorphone and diazepam considering he was medicated with oxycodone, an opioid. The effects of drugs, under those circumstances, could be severe. Furthermore, combining two drugs could have caused severe side effects like issues with breathing and possible brain death (Fassett, 2011). At the same time, because of the fragility of his health and age, there is a possibility that the sedatives resulted in undesired eventualities on her condition.

            Ideally, doctor T and nurse J should have scrutinized Mr. B’s medical history before heavily sedating him. Similarly, medical practitioners should have applied different, less harmful, sedatives to avoid adverse side effects. In this ideal scenario, Mr. B would have recovered.

            As described by Spath & Hickey (2003), the deteriorating health of Mr. B could have potentially been as a result of the overdose of hydromorphone and diazepam sedatives. Furthermore, a combination of these sedatives with oxycodone (opioids), could have resulted in these complications. The situation was acerbated by Mr. B’s fragile health and age.

            The first step is to create a checklist with all the processes or procedures for patients’ examination to avoid mistakes from reoccurring in the future. At the same time, the creation of policies should be done to facilitate the use of these steps.

Process Improvement Plan

            The appropriate team of medical practitioners will be identified, and the process of identification is likely to result in substantial changes. In this case, part of the plan will comprise collecting data about the specific process requiring change. For example, the current policies will be thoroughly examined to identify gaps causing the problem in question.

Lewin’s Change Theory

Using Lewin’s Change Theory, the improvement plan begins with the change identification and team selection. This action will be followed by conducting the change process. The possibility of the change process causing anxiety to doctor T and nurse J is high, as they may be forced to go for further training, and their routines disrupted. Lastly, enforcing the change will require several measures, and they will comprise employees’ training, supervision, and formulating policies.

General Purpose of FMEA

            The purpose of the FMEA is to carry out a series of actions to reduce or eliminate failures by starting with the ones with the highest priority.

Steps of FMEA Process

            The first step is selecting a process for FMEA evaluation. The process selection for FMEA evaluation is important, considering not every process is appropriate with this technique. The one with the least sub-processes is considered more appropriate in this scenario.

            The second step involves multidisciplinary team recruitment. Such a team is made up of individuals involved with all stages of the process.

            The third FMEA comprise the team listing all the steps as part of the process. Putting together the steps require efforts from all team members, which may take several days. Most importantly, diagrams should be used to make the work easier.

            The fourth step involves listing all the failure modes and causes after identification. Every factor that could potentially result in a process failure is identified, including the possible solutions for every step.