With the continuing growth of ASCs, competition from hospitals, a national nursing shortage and experienced nurses retiring out of the workforce, ASCs are finding it difficult to find ASC-experienced Directors of Nursing and Administrators see Sidebar. This is further exacerbated because there are not enough nurses and administrators experienced in outpatient surgery to meet the increasing ASC demand. While ASCs cannot enlarge the pool of qualified applicants, they can improve their chances of hiring top-notch individuals by attracting the right candidates and taking proactive measures to retain them.
Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health care. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals.
RCA thus uses the systems approach to identify both active errors errors occurring at the point of interface between humans and a complex system and latent errors the hidden problems within health care systems that contribute to adverse events.
It is one of the most widely used retrospective methods for detecting safety hazards.
A multidisciplinary team should then analyze the sequence of events leading to the error, with the goals of identifying how the event occurred through identification of active errors and why the event occurred through systematic identification and analysis of latent errors Table.
The ultimate goal of RCA, of course, is to prevent future harm by eliminating the latent errors that so often underlie adverse events. The hospital was under regulatory pressure to improve its pneumococcal vaccination rates.
Work environment Lacking the appropriate equipment to perform hysteroscopy, operating room staff improvised using equipment from other sets. During the procedure, the patient suffered an air embolism. Team environment A surgeon completed an operation despite being informed by a nurse and the anesthesiologist that the suction catheter tip was missing.
The tip was subsequently found inside the patient, requiring reoperation. Staffing An overworked nurse mistakenly administered insulin instead of an antinausea medication, resulting in hypoglycemic coma.
The patient experienced an opiate overdose and aspiration pneumonia, resulting in a prolonged ICU course. A traditional analysis might have focused on assigning individual blame, perhaps to the nurse who sent the patient for the procedure despite the lack of a consent form. However, the subsequent RCA revealed 17 distinct errors ranging from organizational factors the cardiology department used a homegrown, error-prone scheduling system that identified patients by name rather than by medical record number to work environment factors a neurosurgery resident who suspected the mistake did not challenge the cardiologists because the procedure was at a technically delicate juncture.
This led the hospital to implement a series of systematic changes to reduce the likelihood of a similar error in the future. RCA is a widely used term, but many find it misleading.
Labeling one or even several of these factors as "causes" may place undue emphasis on specific "holes in the cheese" and obscure the overall relationships between different layers and other aspects of system design.
Accordingly, some have suggested replacing the term "root cause analysis" with "systems analysis. A commentary identified eight common reasons why root cause analyses fail to result in improved safety, including overreliance on weak solutions such as educational interventions and enforcing existing policiesfailure to aggregate data across institutions, and failure to incorporate principles of human factors engineering and safety science into error analysis and improvement efforts.
The National Patient Safety Foundation has proposed renaming the process root cause analysis and action RCA2 to ensure that efforts will result in the implementation of sustainable systems-based improvements.
A Annual Perspective discusses the limitations of the current approach to RCA and how the process can be made more effective. As of27 states and the District of Columbia have mandated reporting of serious adverse events increasingly using the National Quality Forum's list of Never Eventsand many states also require that RCA be performed and reported after any serious event.
This growth of mandatory reporting systems has likely increased the use of RCA.Numata et al. () located nine observational studies of the association between nurse staffing and mortality in ICUs, five of which were included in a meta-analysis (Person et al., , Dimick et al., , Pronovost et al., , Amaravadi et al., , Tarnow-Mordi et al., ).
The first four studies listed were conducted in the US and the fifth in Scotland. A CRITICAL ANALYSIS OF ETHICAL AND SOCIAL ISSUES IN IHRM PRACTICES. Print Reference this. Published: 23rd March, Disclaimer: This essay has been submitted by a student. This is not an example of the work written by our professional essay writers.
Critical Issues of Ethics-. Safe Fire Fighter Staffing – Critical Considerations – critical tasks necessary to contain and extinguish fires. When staffing falls below minimum acceptable levels, so does service, and the goals and expectations set by the community are essentially abandoned.
62 5. Scenario Analysis: A Tool for Task Managers Jonathan N. Maack Scenario analysis has been used by the private sector for the last 25 years to manage risk and. We present the results of our analysis and our recommendations to the federal government and national organizations, to institutions, and to nurses.
a "big picture" view of the most critical issues and substantive solution recommendations could be determined. et al.
Nurse staffing and patient outcomes in hospitals. ISSN: X Volume 3, Issue 5 (Sep,-Oct. ), PP timberdesignmag.com analysis of a specific topic or theme without considering the chronological order of which the research has been conducted.
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