I the wrote the following post:Steps of the Problem-Solving Framework. The problem-solving framework in the research report is the root-cause analysis, which comprises steps. The first step involves identifying what happened to the patient, whereas the second step entails determining what should have happened. Besides, the third step encompasses determining the causes, which can be categorized into six groups: communication, training, fatigue, environment, rules, and barriers (Haney, 2020). The last step includes developing causal statements that clarify the contributory factors that led to the patient’s condition. Consequently, the article used the four examples to illustrate the use of root-case analysis (RCA).The problem in the case study involves Liam, an eight-year-old male who collapsed on the basketball field. According to Haney (2020), the registered nurse (RN) never correctly placed the large bore IV in a large vein above Liam’s wrist as directed in the healthcare organization’s policy for caustic medication. As a result, he experienced decreased radial pulse and the capillary refill for more than three seconds. The RN did not assess the IV site, skin, and tolerance every two hours as required. Lastly, the RN did not follow the organization’s policy when placing the vascular or plastic surgery consult. Therefore, Liam could not use his right hand again for daily activities.The root analysis was used because it is effective in investigating adverse events. The framework is an operational method for solving various medical issues. For example, Shea et al. (2019) mention that the framework helped reduce hypoglycemia considerably, with a concomitant decrease in blood glucose levels among various diabetic patients. Additionally, the RCA can help determine why the unexpected situation occurred and how the problems can be eliminated. Team members involved in the different steps of the analysis included the RN, emergency department physician, and the registered nurse team members. Thus, the RCA was the best framework for the scenario.The first step involved the registered nurse (RN) evaluating the circumstances that led to Liam’s right hand not functioning. The emergency department physician reported that the cause of the problem included the RN’s failure to follow the organization’s policy during the administration of caustic medication and lack of assessments on the patient every two hours as required. The second step entailed the healthcare team offering corrective measures for the RN’s mistakes during treatment. Members involved in this stage comprised supervisors and quality improvement experts who analyzed the treatment procedures. They identified the correct actions that could have prevented the adverse result. Besides, the third step comprised the medical team identifying the potential causes of the problem. The team members at this stage comprised physicians, supervisors, the RN, and quality improvement experts. The last step encompassed the RCA team developing causal statements that described how the contributory factors led to Liam’s adverse outcome. Role of the Problem-Solving Framework. The root cause analysis (RCA) framework was selected because it aids health professionals in determining why an undesirable outcome or near-miss occurred in the first place. A root cause analysis is a retrospective, organized study of an adverse event, near miss, or sentinel incident is a root cause analysis. Organizations and people may understand what occurred and why by utilizing RCAs to analyze the events, dangers, and vulnerabilities in their systems of care. Healthcare companies may better understand the conditions that led to an unsatisfactory result or near miss, what safety regulations were breached, and where individual providers or the company as a whole failed by doing root cause analysis A variety of active failures, latent conditions, and contributing factors combine to cause adverse events in healthcare (Haney, 2020). Because of this, RCA employs a systems approach to find both active and latent errors (errors that occur at the point at which humans interact with a complex system) (the hidden problems within health care systems that contribute to adverse events). In retrospect, it is one of the most widely used techniques for identifying inherent hazards to health and safety. The ultimate goal of RCA is to prevent future harm by eliminating the latent errors that so often underlie adverse events (Agency for Healthcare Research and Quality, 2019).The framework was very effective in understanding the cause of the patient’s adverse outcome. It addressed the initial problem and the mediation procedure conducted by the RN. Besides, it analyzed the various mistakes made during treatment that resulted in the patient’s adverse effects. The article mentioned that identification of various items that led to the problem would help avoid such an outcome in the future. Additionally, medical practitioners must carefully follow the organization’s procedures during every treatment. Rodziewicz et al. (2018) mention that some of the causes of medical failure include deficiencies in education, incomplete assessment, inadequate policies to guide healthcare works, lack of consistency in procedures, and poor supervision. Thus, the framework helped the medical practitioners identify some of these factors as the major causes of the problem. The Framework Selection in the Research. In this case study, Haney (2020) claims that an IV potassium extravasation caused necrosis and loss of function in Liam’s dominant right hand. Numerous opportunities were discovered after a comprehensive root-cause study. The best method to prevent this damage from occurring again is to clearly define action items to enhance the system or processes and indicate which stakeholder is accountable for each action.On the one hand, when a patient expresses pain or discomfort, the nursing staff at this facility must be retrained to communicate and assess the situation. Reeducation should also include how to avoid IV extravasation and what to do if it does occur, as laid forth in the facility’s current policy currently. Nurses should also remember that electronic alerts and barriers protect patients and should not be quickly dismissed (Haney, 2020).On the other hand, compliance with education should be the facility’s primary goal. A lack of education or behavioral compliance can be resolved quickly if all required staff members complete their assigned learnings (Haney, 2020).Finally, the facility should examine nurse-to-patient ratios, patient acuity in each nurse’s assignment, and ways to ensure that each nurse’s patients are in close proximity. As a result, the RN would not have had to deal with as many high-acuity patients during her shift in various parts of the facility (Haney, 2020).Therefore, it is essential to conduct random audits throughout the year to confirm that all action items have been performed and that overall compliance has improved. The institution may guarantee that the RCA was successful and relevant by frequently monitoring and analyzing the efficacy of the RCA action items. Additionally, it can continue to decrease the risk of patient harm (Haney, 2020).The framework selection was adequate for the case study under investigation. The framework is also suitable because it is the best method for addressing the issues in the case study. The RCA uses a chronological manner to review care by groping various treatment categories to understand the situation. The primary advantage of this strategy is that it demonstrates the failures that occurred at different systems and the organizational levels that led to patient harm. When a situation occurs, the system uses a team approach to accrue empirical data on what happened and the causes (Balakrishnan et al., 2019). The information helps the organization to develop policies and procedures that would help prevent future medical errors. Hence, the selected framework was practical. My question is: The hospital’s actions towards the staff involved often centers around whether or not they adhered to the policies. Do you feel the consequences should take this into account in this situation? Health Science Science Nursing IHP 604 Share QuestionEmailCopy link Comments (0)
Recent Comments