University Nursing Sensitive Indicators Case Study Analysis Report

This report presents a case study analysis of a nursing sensitive indicator incident, focusing on a patient's experience in a hospital setting. The analysis begins with a root cause analysis (RCA) to identify the underlying factors contributing to the incident, which involved a Jewish patient being serv...Read More

Running head: NURSING SENSITIVE INDICATORS
CASE STUDY ANALYSIS REGARDING NURSING SENSITIVE INDICATORS
Name of the Student
Name of the University
Author note

1NURSING SENSITIVE INDICATORS
Table of Contents
A. 1. Root Cause Analysis (RCA).......................................................................................2
Introduction......................................................................................................................2
Event description.............................................................................................................2
Chronology of events.......................................................................................................2
Investigation team............................................................................................................2
Finding and root cause.....................................................................................................3
Corrective action..............................................................................................................3
B. 1. Improvement plan.......................................................................................................3
Change theory..................................................................................................................3
C. FMAE model...................................................................................................................4
References............................................................................................................................6

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A. 1. Root Cause Analysis (RCA)
Introduction
This section is going to highlight the purpose and importance of the Root cause analysis
(RCA) of the incident happened with Mr. J. Once, the analysis will be completed the list of root
causes will be identified and finally those root causes will be evaluated to implement several
changes in the working culture of the hospital (Davis Giardina et al., 2013).
Event description
After a drastic fall and a right hip fracture, Mr. J was admitted in hospital, which was
situated in a city of few Jewish people. That day, the food order for Mr. J was regular kosher
chopped meat, however, the food supervisor mixed the order and mistakenly Mr. J was served
with the chopped pork.
Chronology of events
 Mr. J admitted to hospital after a fall and right hip fracture.
 Mr. J ordered the food regular kosher chopped meat. However, the supervisor
served chopped pork meat.
 Her daughter came to know the incident and informed the physician and higher
authorities.
Investigation team
The investigation team consists of the Jewish physician and few higher authority
representatives. They interviewed the food supervisor and the other departments to investigate
the event.

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Finding and root cause
It was found that the staff were not aware of nursing sensitive indicator and the prime
reason behind it was negligence about the need of the Jewish community people.
Corrective action
The corrective action of this fault should be training and education of the nursing staff
regarding the needs of Jewish community.
B. 1. Improvement plan
After this incidence, to make sure that such incidence never happens again, the entire
nursing staff were interviewed to understand their knowledge about the Jewish community. The
city in which this hospital was situated had very less amount of Jewish community and therefore,
maximum of the staff were not aware of their cultural, social and food related preferences.
Therefore, as per the corrective action of the RCA, the nursing staff should be provided with
training and education sessions so that the staff become aware of the food and dietary habits of
the Jewish community for future (Craft et al., 2012).
Change theory
Lewin’s three-stage change theory model is a simple and effective model to implement
changes and commonly termed as Unfreeze, Change and Freeze (Shirey, 2013). The following
table describes the three steps in tabular form.

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C. FMAE model
This model is known as Failure model and effective evaluation. It is applied in this case
because a team of investigators found out the flaws in the process and hence, evaluation becomes
necessary (Paterno, 2012).
Steps Strategies
Review of the process Ethical mistake in care for a Jewish patient
and negligence about his dietary habits
Brainstorm potential failure modes This negligence can lead to failure as the
patients are complaining about such problems
to the hospital authority
Potential effect of failures Jewish will not prefer the Hospital in near
future as their needs are being neglected
Unfreeze
A consensus will be
taken from the
employees so that
their agreement in
the change can be
made sure.
Change
The change will be
introduced in the
organization and
every staff will be
given training
regarding the change
Freeze
to ensure that the
chnage is
permanent, every 3
month interval, a
survey will be
conducted to keep a
track of the
knowledge about the
Jewisdh people in
the staff.

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consecutively.
Severity rankings 8 on a scale of 10
Occurrence ranking 7 on a scale of 10
Detection ranking 5 on a scale of 10
Calculate RPN 75
This table describes the seven steps of the FMAE model. The last four points, point out
the severity, outcome detection and RPN of the incident happened. Former three are indicator of
the issue happened in the hospital. Depending on the fourth RPN is calculated by multiplying the
former three results. RPN stands for Risk Priority Number and the severity of the incidence is
evaluated using this as a parameter. As the total RPN is in moderate level, the risk in the hospital
has been calculated as moderate level.

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References
Craft, D. L., Hong, T. S., Shih, H. A., & Bortfeld, T. R. (2012). Improved planning time and plan
quality through multicriteria optimization for intensity-modulated
radiotherapy. International Journal of Radiation Oncology* Biology* Physics, 82(1),
e83-e90.
Davis Giardina, T., King, B. J., Ignaczak, A. P., Paull, D. E., Hoeksema, L., Mills, P. D., ... &
Singh, H. (2013). Root cause analysis reports help identify common factors in delayed
diagnosis and treatment of outpatients. Health Affairs, 32(8), 1368-1375.
Paterno, F. (2012). Model-based design and evaluation of interactive applications. Springer
Science & Business Media. https://books.google.co.in/books?
hl=en&lr=&id=ylQFCAAAQBAJ&oi=fnd&pg=PA1&dq=Failure+model+and+effective
+evaluation&ots=19XCagFYHM&sig=pICoeeXEoTdC8uJkidUVFZPDia0#v=onepage&
q&f=false
Shirey, M. R. (2013). Lewin’s theory of planned change as a strategic resource. Journal of
Nursing Administration, 43(2), 69-72.