Health essays

free essayThe patient safety problems can be classified into term errors, communication failures, inappropriate patient management, and low-quality clinical performance before, during, and after the patient’s intervention. Root cause analysis can help to identify current problems in healthcare process.

Root Cause Analysis

According to the scenario, Mr. B’s death was caused by wrong actions made by the LPN on duty.  Since the hospital policy requests the importance of successful completion of the hospital’s moderate sedation training module for all practitioners, the LPN on duty was not responsible to repeat the B/P reading, when the nurse J was busy with the other patient. In terms of the classification of the types of errors and harm, there was an active failure based on the direct contact of the LPN on duty with the patient Mr. B. Thereby, the main problem is wrong actions of the LPN on duty, which cause the death of Mr. B. Indeed, it is more problematically, since Mr. B has only broken his leg and was resting after the sedation, when the problem occurred. There are several issues connected with the incident.

Get a price quote

The first problem is that LPN on duty was not responsible to provide care for the patient (repeat the B/P reading) since he had not completed moderate sedation module. The second problem is that the patient was sleeping when the B/P procedure was repeated, even despite the fact that hospital sedation policy requires that the patient should meet specific discharge requirements (i.e. fully awake, VSS, no N/V, and able to void) during the B/P procedure. The third problem is that trained nurse was not available for the patient, who was being monitored via blood pressure monitor. The next problem is that LPN on duty did not call the emergency department physician or trained nurse for the patient, when the monitor began to alarm.

All mentioned problems have several causes connected with the medical aspects of patient care. First of all, it is the lack of adequate trained personnel. For example, for sixty-bed rural hospital, there was only one nurse, who had completed moderate sedation module, and there was only one emergency department physician. Secondly, the next cause of the existent problems is the lack of adequate training facilities for the available personnel. Thereby, the LPN on duty was not able to provide proper care for the patient.

Improvement Plan

The patient care improvement is a dynamic process and should be based on the appropriate improvement plan. In order to achieve this objective, the development and sustenance of a patient-sensitive system should be provided. Thus, it is necessary to pay attention to quality in every aspect of patient care, both medical and non-medical ones. A proposed improvement plan is to decrease the likelihood of the given scenario problems reoccurrence. Thus, in order to prevent recurrence, the next specific changes were recommend.

First of all, there is a need for increasing the number of staff training programs and improving the existing ones. Thereby, new and improved training programs will cause the increase in the number of the trained staff responsible for high-quality patient care. Secondly, the use of newer technologies is important for improving the existent level of the patient care quality. It is also necessary to mention, that these described improvement steps should be done with reference to cost efficiency.

Save 25% on your ORDER Save 25% on your ORDER

Exclusive savings! Save 25% on your ORDER

Get 15% OFF your FIRST ORDER (code: leader15) + 10% OFF every order by receiving 300 words/page instead of 275 words/page

On the other hand, the care process should also be improved, since previously mentioned patient safety problems were classified in terms of errors because of the communication failures between the LPN on duty and other emergency department staff.  In order to provide better communication system between the staff members, the next steps should be implemented. The first step is to provide staff with such communication technologies as working telephones or radios. This will allow speeding the communication processes between the staff members in different parts of the emergency department. The second step is to provide clear recommendations about the delivering health care. For example, it is important to mention to new staff, especially to interns and the like, that if they are not responsible for some procedures, they need to immediately call the responsible nurse or physician.

Change Theory

A change theory is the general concept of developing the specific areas of the improving healthcare processes in the organization. Creative use of different change concepts will help to develop a specific knowledge for implementing changes throughout the organization. According to Langley et al. (2009), a useful change theory for the given case is the concept of improving the workflow and error proofing. For instance, improving the workflow will allow constructing the process steps that will help to speed it and obtain proper quality at lower costs. Indeed, the error proofing will help to avoid mistakes in delivering health care (Institute for healthcare improvement, 2013). For example, errors could include wrong dosage of medication or improper medical staff behavior that can lead to the complications in the patient’s health.

Failure Modes and Effects Analysis

Failure Modes and Effects Analysis (FMEA) is a method for evaluating healthcare process. In order to identify the parts of the process that are most in need for a change, the FMEA identifies where and how it might fail and assesses relative influence of  different failures (Institute for Healthcare Improvement, 2004). Thus, the FMEA provides substantial support to imagine how successful the improving plan will be. This method is based on describing the following part of the improvement plan. The first part contains steps in the process; the second part contains failure modes, which describe what could go wrong; the third part describes the failure causes, which answers the question, why would the failure happen; and the fourth one characterizes the failure effects that contain the consequences of each failure (Institute for Healthcare Improvement, 2004).

Members of the Interdisciplinary Team

The interdisciplinary ieam consists of four members, who were defined as the most active healthcare staff. In order to provide the effective changing process, this team contains every profession involved in delivery of the healthcare process from those who regularly perform it. For example, it is consisted of the nurses’ supervisor, emergency department physician, and two nurses working in shifts. The physician from the other emergency department was chosen as a representative of the process. The leader of the team is the head of the district’s health department.

Our Customer Support Team is at Your Disposal 24/7


Furthermore, the steps that occur before the actual FMEA begins are described below. The first step in the Failure Modes and Effects Analysis is the selection of the process to evaluate (Institute for Healthcare Improvement, 2004). As it was mentioned in the part “A. Root Cause Analysis”, the process that requires improvement is training of new staff responsible for high-quality patient care. This will help to avoid many problems that have been created because of the wrong actions of medical staff.  The second step is to recruit an interdisciplinary team (Institute for Healthcare Improvement, 2004), which was described in part “C1. Members of the Interdisciplinary Team”. The third step of the FMEA preparation is to conduct several meetings between the team members, where they will list all the steps in the evaluation process.

Three Steps

The next stage of the FMEA is defining the severity, occurrence, and detection ratios of the existed problems. The severity rates include important elements for the organization, such as providing high safety standards. Severity rating shows the possibility of the harm occurring in the case of the failure mode. Its score may vary between 1 and 10, and the higher score is, the higher is the possibility that severe harm will occur.  In case of the given emergency department, the fault will cause the death of the patient. Thus, such failure mode as staff mistakes should have 10 score in severity rating (Carlson, 2014).

Our Benefits

  • English Speaking Writers
  • Plagiarism Free Papers
  • Confidentiality Guaranteed
  • VIP Services
  • 300 Words/Page
  • Affordable Prices

The occurrence rating defines the probability of a failure that occurs during the expected lifetime of the service (Carlson, 2014). Thus, this indicator is based on a functional breakdown of the healthcare system in the emergency department. For example, it can predict the possibility of the fact that nursing staff will make a mistake in the care process.

The detection ratio characterizes the probability of detecting the problem. It also includes isolating the problem and maintaining time (Carlson, 2014). For example, in the described problem, it took 7 minutes to find that the LPN on duty has made a mistake which cause the deterioration of the patient’s health. However, it did not help to prevent death of the patient.


Plan-Do-Study-Act (PDSA) cycle is an appropriate method for testing the quality improvement before its overall launching throughout the organization. The first stage of the PDSA is the plan stage. It occurs at the planned meetings, which were described in the part “C2. Pre-Steps”.  At the second stage of this cycle, an interdisciplinary team should carry out a small-scale test of the planned action. During this stage, they need to observe and document any unexpected events or problems and collect data. This data then will allow determining the impact of the test on the improving plan (Langley, 2009). The third is the study stage. During this stage, the team members should analyze the collected data and observations, and compare these findings to the expected indicators.  The last stage is the acting. During this stage, the improvements to the plan are made. Further, the team members can also decide either to proceed to full-scale implementation or again to test the change with some modifications (Langley, 2009).

How It Works

Key Role of Nurses

Senior nurses play important roles as leaders who help shape healthcare quality and patient safety (Middleton, 2011). They also should provide successful introduction and implementation of advanced practice nursing roles in their organizations. Nowadays, nursing role in influencing all aspects of healthcare delivery is increasingly growing. For example, senior nurses should develop other employees by enabling them to apply theory to healthcare practice. Furthermore, they need to encourage them to test new skills in a safe and supportive environment, which will help them to improve patient safety. Indeed, nurses also need to resolve tensions between professional disciplines and build an effective relationship between the interdisciplinary team members (Middleton, 2011).


The root cause analysis allowed dividing existent problems in the emergency department in terms of healthcare delivering services. According to it, the major problem of this organization is the lack of the qualified staff being responsible for complex medical operations. As a result of the failure modes and effects analysis, an appropriate improvement plan was developed.

Organizational Systems and Quality Leadership in Healthcare

The patient safety problems can be classified into term errors, communication failures, inappropriate patient management, and low-quality clinical performance before, during, and after the patient’s intervention. Root cause analysis can help to identify current problems in healthcare process. Root Cause Analysis According to the scenario, Mr. B’s death was caused by wrong actions made by […]

The Most Important Discoveries in Biology of the XIX and XX Centuries

In the science of the XIX and XX centuries, endless revolutionary changes in all branches of natural sciences occured. By the middle of the XX century, one of the central places among the natural sciences was occupied by biology. The last two centuries have seen such fundamental discoveries as the foundation of the theory of […]

HIPAA (Health Insurance Portability and Accountability Act)

HIPAA stands for Health Insurance Portability and Accountability Act that was passed in the United States Congress in 1996. HIPAA was adopted to cater for health needs of American workers and their families. Nearly everybody understands the sensitivity of health and medical information. However, the privacy of health information and its security remains to be […]

Healthcare Strategic Planning of Brooklyn Hospital Center

Brooklyn Hospital Center was founded in 1845 in Brooklyn, New York, USA. It is a non-profit institution with the main goal of improving healthcare services to the community and New York as a whole. It was named Brooklyn City Hospital under the influence of Mayor Smith at that time (Ball, Weaver & Kiel, 2013). After […]

Theories of Influence and Power and its Effectiveness

A healthcare organization setting is a challenging one. As a result, it demands qualifying leaders that will promote continuous quality improvement and provide patient satisfaction. Effective leadership is the basement of the development and progress of any healthcare establishment. It means that a leader should be ready to have his/her model of behavior, patterns of […]

Importance of Utilization of Evidence-Based Practices

This essay will show the importance of understanding by nurses their great role in utilization of evidence-based practices. They can improve their working process, provide more effective and efficient treatment to patients, participate in development of new treatment methodologies, and challenge the effectiveness of the existing ones. Much attention is devoted to the necessity of […]

Long Working Hours Linked to Increased Risky Alcohol Use

Extensive research has been conducted to establish the link between long working hours and increased risky alcohol use among individuals. It is vital to understand the relationship between long working hours and alcohol consumption of different groups of individuals including adolescents, men, and women. Risky alcohol consumption exposes individuals to numerous health problems including mental […]

Food Safety Training Manual

Nowadays, the issue of food safety is quite relevant. Everyone knows the importance of consumption of the fresh and healthy of high quality. In fact, food significantly influences the health, performance, psychological state, and longevity of the individuals. Nevertheless, each year, the pathogenic bacteria, viruses, parasites, or chemicals contained in food are supposed to be […]

Risks of Coffee

There is an on-going debate about advantages and disadvantages of coffee impact on the human health. Many people know of some of its benefits, such as positive effects on energy and cognition, as well as reduced risk of Parkinson’s disease and diabetes. However, there are several risks associated with coffee consumption. This essay discusses the […]

GERO Paper

1. Discuss the concept of cumulative disadvantage. How does this concept apply to older adults in the areas of health, economics and relationships? How do gender, ethnicity and class affect cumulative disadvantage? Historical events of the last years led to intensive social and economic stratification of the population in the whole world. Social polarization is […]

The U.S. Health Care System (MCAA Training Manual)

The Healthcare system of the United States of America is the world’s largest health care system in terms of expenditure. However, much about the US healthcare system relates to the system’s controversial inability to be at par with the healthcare systems of other countries that belong to the developed world. However, the US healthcare system […]

The Effects of Prolonged Steroid Use on the Human Body

The latest decades have revealed significant growth of steroid abuse patterns. Modern medical statistics allows an acute assessment of the undesirable side effects of steroid use on the human body. When steroids are prescribed with medical intentions, the doctors instruct on the adherence of dosage and rate of application, so that to a certain extent, […]

A New Road to Health Care: From Treatment to Prevention

Healthcare systems place emphasis on three main functions, which include cost reductions, improvement of health outcomes, and improving patient satisfaction. In this regard, the preventive healthcare approach is more effective than the traditional treatment model with respect to these functions (Sultz & Young, 2014).  With respect to this, it can be argued that traditional healthcare […]

Health Promotion

Introduction Health promotion is a medical process that aims at attaining full mental, physical, and well-being of people in the society. It enables people to have total control of their health and as a result of this, improves their life span. Considered as an everyday life resource, health must be taken care of in order […]

Health Care Safety and Quality

The wide use of health care services, the abuse of some services, as well as overuse and underuse of other ones reveals a broad scope of quality problems that exist in a modern healthcare system. The Department of Health and Human Services in conjunction with other specialized agencies and non-governmental organizations recognize the improvement of […]

Great P. H. Achievements United States

Decline in deaths from coronary heart disease and stroke has become one of the most important public health achievements in the twentieth century. This important achievement has become a reality due the development of medicine and new technology. Thus, using sophisticated advanced treatment due to more effective prevention techniques and diagnoses made it possible to […]

Health Status Gap Between Racial and Ethnic Groups

Racial and ethnic disparities within the health care service are witnessed in diverse ways. For example quality of care, access and insurance coverage are among the several factors leading to inequality in United States health status. Such disparities could be only effectively removed through political good will. This proves to be difficult as their origin […]