The ethics of whistle-Blowing Essay Example | Topics and Well Written Essays - 500 words

The ethics of whistle-Blowing - Essay Example These are people within the organization that see violations in business policies and report them to the relevant authorities. Many things are brought about by this behavior, ranging from honest business practices to mistrust among co-workers. There are certain considerations that have to be made when reporting malpractices in the business. Whistleblowing affects the way the business relates to its environment, and the way co-workers relate with each other. Whistleblowing is the act of reporting a malpractice, wrongdoing or risk to the police, employer, customer, or a regulator (Davis, 2006). There are many instances, such as these found in an article about ethics by Verschoor (2013). An example of a case found in the article is one where an employee reported his employer for malpractices. In New York, Mohanbhai Ramchandani reported his employer and celebrity tailor Ramchandani for not reporting all of his profits in sales and taxes. According to Verschoor (2013), the employee was paid $1.1 million dollars for whistleblowing. Based on the analysis of this case, whistleblowing was the correct decision. This is because no one else can identify fraud apart from the people in the organization (Bouville, 2007). There could be acts involving corruption affecting, honest business practices that go against the law. Therefore, it is necessary for people to monitor business practices and report unhealthy business forms. The act of whistleblowing is an act involving business ethics that has its benefits and demerits (Davis, 2006). A benefit of whistleblowing is that it protects investors of businesses from people that look to mismanage money for their own benefits. Unsuspecting customers also benefit from people who report malpractices in business. For example, a whistleblower protects patients from a doctor who overcharges for services and uses questionable means in administering

Homework Assignment Essay Example for Free

Homework Assignment Essay 1. Define the process of accounting. Accounting is the process of identifying, measuring and communicating economic information about an organization for the purpose of making decisions and informed judgments. 2. What are the three major divisions in the accounting field? Financial, managerial and cost accounting 3. What is the Fundamental Accounting Equation? Assets = Liabilities + Equity 4. What is the purpose of a balance sheet? What are some examples of typical balance sheet accounts? A balance sheet is a summary of financial balances of an organizations assets, liabilities and equity listed on a specific date such as the end of year report. A balance sheet is a snap shot of the company’s financial status 5. What is the purpose of an income statement? What are some examples of typical income statement accounts? An income statement is also known as profit and loss statement is one of the financial statements of a company and shows revenues and expenses during a particular period. An income statement indicates how the revenues are transformed into net income 6. What is the purpose of a statement of cash flows? What are some examples of typical statement of cash flow accounts? A cash flow statement consists of three parts; operating, investing and financing. It is the summary of transactions that affected cash in a particular period. In other words, it si a summary of all the cash payments and the cash receipts that occurred during a month, quarter or year for a business. 7. Based on the financial information below, prepare an income statement and a balance sheet for Joe’s-Fly-by-Night Oil company for the year ended December 31, 2012. Unless otherwise indicated, assume all information below is either for the year 2012 or as of December 31, 2012.

Role of Consumer Expectations in Economic Policy

Role of Consumer Expectations in Economic Policy BU/12C/BS/0403 Introduction A theme that dominates modern discussions of macro policy is the importance of expectations, and economists have devoted a great deal of thought to expectations and the economy. Change in expectations can shift the aggregate demand (AD) curve; expectations of inflation can cause inflation. For this reason expectations are central to all policy discussions, and what people believe policy will be significantly influences the effectiveness of the policy. Expectations complicate models and policymaking enormously; they change the focus of discussions from a response that can be captured by simple models to much more complicated discussions. The adaptive expectations theory assumes people form their expectations on future inflation on the basis of previous and present inflation rates and only gradually change their expectations as experience unfolds. In this theory, there is a short-run tradeoff between inflation and unemployment which does not exist in the long-run. Any attempt to reduce the unemployment rate blow the natural rate sets in motion forces which destabilize the Phillips Curve and shift it rightward. Under adaptive expectations, forecasts of the future rate of inflation may be right on the money, but they may also exhibit systematic error. When inflation is accelerating, forecasts will tend to be too low. And when inflation is decelerating (that is, disinflation is taking place), then forecasts will tend to be too high. The Rational expectations model was developed by Robert Lucas, rational economic agents are assumed to make the best of all possible use of all publicly available information. Before reaching a conclusion, people are assumed to consider all available information before them, then make informed, rational judgments on what the future holds. This does not mean that every individual’s expectations or predictions about the future will be correct. Those errors that do occur will be randomly distributed, such that the expectations of large numbers of people will average out to be correct. To illustrate, assume the economy has been in an equilibrium state for several years with low inflation and low unemployment. In such a stable environment, the average person would expect the inflation rate to stay where it is indefinitely. But now assume the Central Bank announces it is going to significantly increase the rate of growth of the money supply. Basic economic theory tells us an increase in the money supply will translate into higher prices, such that increasing the annual rate of growth of the money supply should bring about higher inflation rates. Knowing this, consumers will revise their inflationary expectations upward. As this simple example shows, people do not rely only on past experiences to formulate their expectations of the future, as adaptive expectations theory suggests. Rather people use all information available to them in judging what the future will hold. This information can include past data, but it will also include current policy announcements and all other information that give them reason to believe that the future might hold certain changes. If the adaptive expectations are backward looking the rational expectations are forward looking , in that they assume people will use all of the information available to them. Expectations of inflation Some workers may feel cheated by inflation. They might believe that without it, they would experience real-wage increases because their nominal wages are rising 5% a year. Unfortunately, they are wrong. They suffer what some economists call money illusion, a confusion of real and nominal weight. The source of the illusion is as thus; considering real wages are constant, the rise of their nominal wages by 5% is only as a result of the general 5% inflation. Assuming no inflation took place, there will be no increase in their nominal wages. After a time, everyone in the economy will begin to expect that the 5% annual inflation that ensued in the past would continue in the future. Economists refer to this as expectations of inflation. People’s expectations of inflation influences all facets of economic life. For example, in the steady-state economy described previously, textile producers will look forward to increasing the price of their products by 5% for the coming years. They will also expect their costs of steel and labor, for example, to increase the same way. Workers will begin to believe that the increase in their wages will be matched by the same increase in the prices of goods they buy. Also, wages are influenced by expectations. Suppose, for example, that both employers and employees expect 4% inflation in the year coming. Workers will start negotiations from a base of a 4% increase in money wages, which would hold their real wages constant. Firms also may be inclined to begin bargaining by yielding to increase at least 4% in money wages relative to productivity, because they expect that the prices at which they sell their products will rise by 4%. Starting from that base, workers will attempt to obtain some desired increase in their real wages. At this point, such factors as profits and bargaining power become important. The general expectation of some specific inflation rate creates pressure for wages to rise by that rate relative to productivity and, thus, the rise of unit cost at that rate. Inflation expectations and Interest rates When the public expects inflation, real and nominal rates of interest will differ because inflation needs to be accounted for in calculating the real return from lending and borrowing. Have in mind that the nominal interest rate is equal to the real interest rate plus expected inflation rate. If real rate of interest is 2% and inflation is 5% a year, the nominal rate is 7%. Although lenders receive 7% a year on their loans, their real return after inflation rate is just 2%. We know that in the long run the real interest rate does not bank on monetary policy because money is neutral; i.e. the price level is affected by the money supply. However, the nominal rates of interest do bank on monetary policy because the policy influences the rate of inflation, which in the long run is bent on the growth of the money supply. It has been pointed out that countries with greater money growth naturally have higher nominal interest rates than countries with lower money growth rates because they have higher inflation. What this means is that country A and B have the same real rate of interest, but country A has a higher inflation rate, it will also have a higher nominal interest rate. Inflation expectations and money demand The amount of money people want to hold will also be affected by expectations about inflation. If the public expects a 5% inflation a year, then its demand for money will also increase by 5% a year. This is because people know everything will cost 5% more, so they’ll need more money in their possession to pay for the same goods and services. This is an example of the real-nominal principle: As long as the government allows the increase in the supply of money by 5% , the same amount as inflation, the demand for money and supply are both growing at the same rate, real and nominal interest rates will not change. Effects of expectations on changes in future income Todays consumption decisions may depend not only on current income, but also  on the income that one expects to earn in the future. For example, an individual  who is currently not employed but who has a contract to begin a high-paying job  in three months will probably consume more today than another unemployed  individual with no job prospects. To illustrate the effect of changes in expected future income, suppose that  instead of receiving the $6000 bonus during the current year, a consumer learns that  she will receive a $6000 bonus (after taxes) next year. The promise of the bonus is  legally binding, and said consumer has no doubt that extra income will be received  next year. How will this information affect the consumer’s consumption and saving in  the current year? Because current income is unaffected, the consumer could leave her current  consumption and saving unchanged, waiting until the bonus is actually received  to increase her consumption. If her decisions are guided by a consumption-smoothing motive, however, she will prefer to use the bonus to increase her current consumption  as well as her future consumption. She can increase her current consumption, despite the fact that her current income remains unchanged, by reducing her current saving (she could even dissave, or have negative cu rrent saving, with current consumption exceeding current income, by using her accumulated assets or by borrowing). Suppose, for example, that consumer decides to consume $1000 more this year. Because current income is unchanged, the $1000 increase in current consumption is equivalent to a $1000 reduction in current saving. The $ 1000 reduction in current saving will reduce the available resources in the next year, relative to the situation in which her saving is unchanged, by $ 1000 X (1 + r) . For example, if the real interest rate is 0.05, cutting current saving by $1000 reduces the available resources next year by $1000 X 1 .05 == $1050. Overall, her available resources next year will increase by $6000 because of the bonus but will decrease by $1050 because of reduced current saving, giving a net increase in resources of $6000 $1050 == $4950, which can be used to increase consumption next year or in the following years. Effectively, the consumer can use the increase in her expec ted future income to increase consumption both in the present and in the future. To summarize, an increase in an individuals expected future income is likely to lead that person to increase current consumption and decrease current saving. The same result applies at the macroeconomic level: If people expect that aggregate output and income, Y, will be higher in the future, current desired consumption, cd, should increase and current desired national saving, sd, should decrease. Economists cant measure expected future income directly, so how do they  take this variable into account when predicting consumption and saving behavior? One approach is to survey consumers and ask them about their expectations. Their  answers can be useful for assessing developments in the macroeconomy.   In conclusion, The central role of expectations means that there is a great deal of uncertainty in the economy. Put simply: What people believe plays a central role in how they react to policy. Expectations can change the effect of a policy. Most discussion of policy today assumes that people are forward looking, that they think strategically, and that they base their actions on expected policy actions. Thus in some way their expectations are rational. But modern policy discussion is also built on the belief that the economy is complicated and that many possible expectations are rational. This includes adaptive expectations and combinations of expectations strategies. What the above assumptions mean in terms of policy is that depending on the beliefs that individuals hold, monetary and fiscal policy will work in different ways. People aren’t stupid and they aren’t super intelligent; they are people. If the government uses an activist monetary and fiscal policy in a predictable way, people will eventually come to build that expectation into their behavior. If the government bases its prediction of the effect of policy on past experience, that prediction will likely be wrong. But government never knows when expectations will change. Let’s consider an example. Say that everyone expects government to run expansionary fiscal policy if the economy is in recession. In the absence of any expected policy response from the government, people will lower their prices when they see a recession coming. Expecting government expansionary policy, however they won’t lower their price. Thus, the expectation of policy can create its own problems. References: Advanced Macro Economics, Romer, 2011; Slavin S., Macro Economics, 2009; A Century of Economic Theory. Mankiw, Mcroeconomics, Aggregate Supply and the Short-Run Tradeoff Between Inflation and Unemployment: Business Cycle Theory: The Economy in the Short Run   Rittenberg Tregarthen Micheal Rousakis, uni of warwick, economics and fluctuations: the role of monetary policy, 2012 Froyen, Macroeconomics Weil, Economic Growth

The influential factors behind the growth of globalisation

The influential factors behind the growth of globalisation Current business environment is more volatile and dynamic. There are different reasons behind this transformation in the world. Globalisation is one of the main factors that behind the above change. We can define globalisation as a process by which the world is becoming increasingly interconnected as a result of massively increased trade and cultural exchange. Earlier existed boundaries between countries in the world have been dramatically reduced due to the globalisation. This is seen as more than simply a way of conducting business- it can be considered as a continues process. This is not a new force that emerged few years back, it has been taking place for hundreds of years but it has speeded up enormously over the last half-century. In History, in a similar manner, the techniques of industrial manufacturing lead to create the process of industrialisation, now that process has linked with the globalisation and has created new environment of operating businesses. There are few influential factors behind the growth of globalisation. Increase in communication technology is one of them. TV, telephony and the internet have permitted information and ideas to travel quickly. As an example USA businesses can have a call centre in Philippine or India answering calls from local customers. Another factor is improvements in the transportation sector. It has become more quick and cheap. People can go for holiday all around the world. Workforce can seek for a job opportunity available in another country. Businesses can easily ship their product and raw materials all over the world. Another main influential factor behind the growth is trade liberalisation. This has been excelled due to the Laws restricting for free trade and fo reign investment movements have been relaxed between countries. Some governments even offer grants and tax incentives to attract foreign companies to invest in their country. These actions have lead to create free trade zones in the world. In other words theses are known as trade blocs where groups of nations who form an economic union or customs union. Governments follow friendly rules and regulation within those regions for trading purposes. For example the European Union (EU) aims at not just a customs union but also economic union by way of harmonisation of taxes, establishing a common monetary policy and moves towards a single currency. EU has now expanded over 26 member countries and benefited to combined population of 356 million. Trading blocs generally increase the integration and interdependency of the member economies which is speed up the globalisation process. As a result of trading blocs trade amongst the members has increased, which ultimately increase the world trade capacity. Further it gives the opportunity to businesses better access to effective capital and labour markets which increases the movement of labour within the countries and increase investments. For example Poland workers have been well recognized in the UK and Ireland labour markets. As result of the globalisation process international trade has increased dramatically in the 20th century. Many countries get more chances to participate in the world trade. As a result of increase in Foreign Direct Investment (FDI) many labour oriented countries get access to capital market and vice -versa. Their natural resources value has increased and countries have more capability to use them to manufacture export oriented goods. Increase in international trade brings better standard of living through access to many ways of satisfying their needs and wants. Further it is argued that current development of trading blocs help international trade through making global negotiations easier, in the case of trade negotiations.   For example the EU will negotiate as a single trading block making it easier to push through practises which increase free trade. As per the following graph it is arguable that benefits of international trade have been equally distributed among the world population. Globalisation and increase in international trade is probably helping to create more wealth in developing countries and has affected to the balance of international trade. However globalisation is having a dramatic effect on the organisations for good or ill. Some positive impacts are as follows; Increase greater access to capital market. Inward investment by MNCs helps organisation to start new businesses locally and in foreign countries. This will provide new jobs and skills for local people. Companies can bring wealth and foreign currency to local economies when they buy local resources, products and services. Release of government regulation and establishing better infrastructure in the local economy attract foreign investments. China is well known for cheap labour compared to western countries labour cost. This has become a main reason for many organisations moving their businesses to China. Further investment friendly environment through strong financial support (Tax benefits, financial institutes) for new businesses, attract their cheap resources for other countries. Most of the western countries resources are fully utilised and market have become more matures, but there are emerging economies like China, India, Brazil and Russia which consist many untapped cheap resources. Therefore as a result of pressure built up from the Western markets, businesses now moving for those emerging markets. This process has been made easier and more comfortable due to the globalisation. The extra money created by these investments can be spent on education, health and infrastructure of the countries. (Corporate Social Responsibility activities) Achieve economies of scale. Economies of scale means the increase in  efficiency of production  as the number of goods  being produced increases.  Economies of scale lowers the average cost per unit through increased production since fixed costs are shared over an increased number of goods. Initially Adams Smith identified division of labour and specialization are the main factors that lead to economies of scale. However as Globalisation process increases companies get other opportunities to reduce their production cost and achieve economies of scale. Access to lower inputs and specialized inputs in different countries would bring the economies of scale. Costly inputs such as research and development, advertising, managerial expertise and skilled labor now can be outsourced to specialized countries and it will result in increased efficiency and lead to a decrease in the average cost of production and selling. Therefore economies of scale provides  big companies  access to a larger market with lower cost of production and greater margin for their products.    Globalisation increases awareness of events happening in the world. For example, the USA was quickly made aware of the 2011 tsunami in Japan and sent help rapidly in response. Globalisation may help to make people more aware of global issues such as deforestation and global warming and alert them to the need for sustainable development. The sharing of ideas, experiences and lifestyles of people and cultures. People can experience foods and other products not previously available in their countries. Globalisation has resulted in many businesses starting or buying operations in other countries. Companies that operate in several countries are called multinational corporations (MNCs) or transnational corporations (TNCs). Presence in different countries brings interaction with different cultural and social values. On this case business practices that are successful in local country could be act as negatively or positively under different cultural and social values. Therefore it is advisable to find answer to following questions before starting a new venture with another country. What are the main difference between cultures?, Are they matter of learning a new handshake, or do they go deeper than that?, Can cultural differences really have that much impact on the business deal? Etc. Finding solution for those questions is helpful for organisations to handle cultural differences in business expansions. For example language differences, the way they perceive time, traditional and religious believes etc. play a big role in Asian countries. When US and European base organisations move towards the Asian countries the above cultural factors could act as barriers for entry to those markets. In terms of communication US and Europeans are considered as low context cultures, language is direct and explicit, but when it comes to Asian countries they are known as high context cultures where language is indirect. Further as per certain cultural and social practices men dominate in the business sector than the women but in European organisation everyone gets equal opportunity to participate in the operations. Therefore when companies setup new business in a different culture, that company need to customise their corporate culture as per the local cultural values. As an example the US fast food chain McDonalds, large MNC which has nearly 30,000 restaurants in 119 countries, had a problem of sell ing beef burger in India due to the religious believes. Further they launched Mc Rice in Sri Lanka since rice is the main food in the Sri Lankan culture. Likewise multinational companies tend to customise their strategies to overcome certain social and cultural restrictions as well as implement new thing to take advantageous. In current business environment sometimes it is difficult to follow a global strategy for their operation in throughout the world. Therefore most companies tailor their management strategy and organisational structures to respond to the local factors. In other words local responsiveness is essential when a psychic distance is higher in two different countries. As a result of this new relationships will occur in managing businesses globally. Joint venture agreements, alliances etc. are common relationships that business partners follow to reduce their risk exposure in the current business environment. Designing of organisational structure and management style is important capture the opportunities available in the market. Some companies follow decentralised structure to increase the speed of decision making in the particular market. Some other companies follow a selective approach by some functions are retain in with the parent country and others establish in different markets. As exa mple GAP Inc.s designing function is conducted in centrally and manufacturing function has been outsourced to Asian countries. This mechanism has benefitted them through utilising Asian countries specialised capabilities of manufacturing to convert their design into practical product. Therefore globalisation process brings new organisational designs and management styles to the market. Local markets work force have now increased and well interact with the MNCs. Earlier they were only involved for lower level operations but now management representation also has increased. This is a good advantage for MNCs to take advantage of innovative skills of the local employees since they have more experience in the particular market. Microsoft has given more concentration on Indian market since that workforce well recognised for IT skills. From employees perspective also this will be a good opportunity for them to utilise their skills effectively. Recognition, income level, career opportunities, opportunity to obtain foreign exposures etc. will be increased through working in multinational company. Their innovative concept could bring to the world market through the help of MNCs. So far this report addressed only the good side of the Globalisation and not that mean it doesnt have a dark side. Following are few negative impacts of globalisation Globalisation operates mostly in the interests of the developed countries, which continue to dominate world trade at the expense of developing countries. The role of developing countries market has become to provide the North and West with cheap labour and raw materials at lower cost. There are no guarantees that the proper benefits from inward investment will benefit the local community in developing countries. Often, profits are sent back to the MNCs parent countries. This has become easier for them due the tax relief offered by the local governments. Further these MNCs with their massive economies of scale, possibility to drive local companies out of business. After that If these MNCs realised that it becomes cheaper to operate in another country than the current one then they move for better opportunity by closing down the factory and make local people redundant. This would be a major hit for the local economy. Increase environmental population due to the high industrialisation. Globalisation is viewed by many as it affects to the worlds cultural diversity and it feared that it may westernise the local traditions and languages. After considering the above negative sides of the globalisation we can state that it is not helping to close the gap between the worlds poorest countries and the worlds richest. In the case of trading blocs, it is argued they create conflicting parties fighting for regional interests not for every ones benefits. As per the World Trade Organisations statistics, the worlds poorest countries share of world trade has declined by more than 40 per cent since 1980 to a mere 0.4 per cent and the poorest 49 countries make up 10% of the worlds population, but account for only 0.4% of world trade. (Online, www.gatt.org) This clearly shows benifits of globalisation has not been distributed equally. Further its doubt that MNCs pay fair amount for the developing countries resources. As a result of these negative reasons poor peoples living standards remain same and the gap between poor countries and rich countries wont reduce. Conclusion Globalisation has a major impact on the business environment as well as the people general life pattern. Within the current knowledge economy, knowledge workers have more opportunities due to the globalisation. Their career is not static as compared to the traditional workers. They always seek better opportunities in the market and as a result of globalisation their career path has extended even for different countries. However, as a MNC, they have more responsibilities and accountability for their actions in the different markets. As a good corporate citizen they must give their focus on improving local social and educational life the local people also. Further they must ensure fair consideration for the resources utilised the developing countries. These will ultimately useful to break the bridge between rich and poor countries.

Dating - An Issue of Personal Choice :: Personal Narrative Essays

Dating - An Issue of Personal Choice First there was the passing notes, hand holding and name-calling of middle school. Then you survived your first heartbreak when your high school sweetheart decided it would be best to be â€Å"just friends.† Now swept away in college life, with an important aspect being dorm life, you hardly take the time to step back and ask yourself, â€Å"What am I doing here? Who’s bed did I just wake up in, and how the hell did I get here?!† Okay, so the second part may not be applicable to all students, but at the same time you cannot deny that it happens, likely more often than one would be comfortable thinking about. If you have not yet taken the time to ponder what it is you plan to do with the so-called â€Å"best four years of your life,† besides studying and eating dorm food, perhaps it is about time you did. What do you want to be accomplishing in these prime dating years? More importantly, is that what you are accomplishing? In short, the purpose of this writing is to discuss the question: â€Å"What role should dating play in college students’ lives?† Initially one might think this is a frivolous subject. On the contrary, there is a quite a range of opinions on the subject with marriage incorporated into a number of them. Marriage is not a frivolous topic. Consequently its precursor, dating, also bears significance. One might also think that college students, being in the midst of their own dating lives, would be able to define dating, be familiar with their intentions, and have a strong concept of where the decisions they make today will take them tomorrow, as they relate to dating. Surprisingly, of the students I spoke with here on the Colorado State University campus, while conducting an informal survey, none would have met that standard. All hesitated greatly when asked to simply â€Å"define dating.† Once done struggling through that answer, they were asked â€Å"In your opinion, what is the purpose of dating in college?† These students’ answers ranged from â€Å"getting laid!† to â€Å"discover more about yourself through others and to find the person you want to marry† to â€Å"I have no clue.† Clearly, the college masses are blissfully unaware of exactly what it is they are doing when they are in pursuit of the attractive sex.

Julius Caesar: Marcus Brutus Mistakes :: Julius Caesar Essays

Julius Caesar: Brutus' Mistakes The theme I picked for Julius Caesar essay is the mistakes made by Brutus. According to Mr. Holtz Brutus was stupid and many mistakes. The first one was him even joining the Conspirators. The second was letting Anthony live and speak at the funeral. The final mistake was his battle plan. Every one does make mistakes sometimes, but mistakes Brutus made where plainly stupid. I feel the first mistake was Brutus joining the conspirators in the first place. His mine was easily manipulated by the conspirators. They gave him the justification he needed to kill Caesar, which was â€Å"its Good of Rome.† The assumption was that Caesar would eventually take the crown, which would never less destroyed Rome according to Brutus thoughts. By making this assumption and joining the other conspirators he set him self up for many problems for him and for Rome. This was one of the fatal mistakes made by Brutus. Brutus actually made two mistakes with Mark Antony. The first was letting Mark Antony live and the second was letting him speak alone at the funeral. When Cassius first suggested that they should kill Mark Antony, which they should of, but the noble Brutus said â€Å"Our course will seem to bloody.† That was not his only mistake with Mark Antony he also let him speak at Caesar funeral. He was warned by Cassius, but Brutus ignored him as usual. When Mark Antony spoke he got crowd on his side and they killed all the conspirators except for Brutus and Cassius (they excepted the angry mob and left Rome). This was some more trouble that was caused by Brutus. In the war Brutus makes another dumb decision. He wanted to go into Rome and take it over, but Cassius wanted them to wait for the army to come. Of course they follow Brutus decision and they are defeated. This was yet another bad decision by Brutus. This final decision he lost his life. I wonder some time who is worst Brutus stupidness or Cassius ignorance.

Organizational Systems and Quality Leadership Essay

A. Complete a root cause analysis that takes into consideration causative factors that led to the sentinel event. (This patient’s outcome) The terms failure analysis, incident investigation, and root cause analysis are used by organizations when referring to their problem solving approach. Regardless of what it’s called there are three basic questions to every investigation: 1. What’s the problem(s)? 2. Why did it happen? (the causes) 3. What specifically should be done to prevent it? (Galley, n.d., ∂ 1) In the case of Mr. J, these were multiple issues that led to and contributed to his unexpected demise after what is usually considered a routinely performed procedure in an emergency department setting. The JCHAO (Joint Commission on Accreditation of Healthcare) defines a sentinel event as â€Å"an unexpected occurrence involving death or serious physical or psychological injury†, (Frain, Murphy, Dash, & Kassai, ∂ 1) and in the case of Mr. B, his death would be considered a sentinel event which would warrant a review by a team of interdisciplinary members of the hospital. In this particular case members of the team would include one or more ED physicians, the RN in the scenario and the LPN, a respiratory therapist, a nursing supervisor, a hospital administrator, the ED nurse manager, a hospital pharmacist, and a risk manager. More staff nurses from the ER could also be involved. A credible and successful root cause analysis will identify all of the elements that contribu ted to the event, an action plan will be developed to prevent the event from reoccurring and ensure that those actions are completed. Action plans should be based on best practices and appropriate standards. (Frain et al., ∂ 10) The scenario presented starts out as what  appears to be an average afternoon shift in a small 6 bed emergency department in a rural hospital. Staffing consisted of one emergency room physician, one registered nurse (RN), on licensed practical nurse (LPN) and a secretary. Due to the size of this particular ER, there appears to be limited staffing and therefore limited resources to handle large volumes of patients and or critical patients. There are two patients already being worked up in the department at the time of Mr. B’s arrival and they are stable, have already been evaluated and they are awaiting further treatment or orders. Mr. B is brought to the ED by private vehicle complaining of left leg and hip pain after losing his balance and falling over his dog. The triage nurse noted that other than the patient displaying tachypnea, his vital signs were otherwise within norm al limits. The patient states his pain level is severe, a â€Å"ten out of ten†, and physical examination finds a shortened left lower extremity with calf swelling and ecchymosis. In triage it is noted that the patients leg is stabilized and he is subsequently moved into a patient room where the admitting RN, Nurse J, takes over and gets a more thorough history of this patient, noting impaired glucose tolerance, prostate cancer and chronic back pain. Mr. B regular medications include Atorvastatin and also Oxycodone for his chronic back pain. The doses and how often he takes these mediations is not provided. Although there is no mention of any radiology studies being performed on Mr. B after his arrival, it is assumed that this was performed before the ER physician completed his evaluation and ordered 5 mg intravenous diazepam to sedate the patient to perform a manual reduction of a dislocated hip. After waiting for 5 minutes, the physician then instructed the RN to administer 2mg of hydr omorphone, a powerful narcotic analgesic. The staff waits five more minutes, after which the physician then instructs the RN to repeat both doses of diazepam and hydromorphone because he is not satisfied with the patient’s level of sedation. It is after these medications are administered that the physician notes patient’s weight and history of opiate use. Five minutes after the last dose of medication is administered a successful reduction of the left hip takes place and the patient remains sedated. The reduction procedure, which initially began at approximately 16:05, ended at 16:30. Although Nurse J is monitoring this patient, she is alerted that EMS (Emergency Medical Services) is bringing in an elderly patient with reported acute  respiratory distress. Nurse J, an experienced critical care nurse, elects to place Mr. J on an automatic blood pressure machine with a pulse oximeter. Although not stated, it is likely that this is a portable machine and is not hooked up to any wall monitors. It does not have continuous EKG monitoring. It does not have end tidal CO2 monitoring. Nurse J then elects to leave the patient in the company of his son with a blood pressure of 110/62 and an oxygen saturation of 92% on the portable machine. The patient is breathing room air and does not have any other monitoring. The ambulance patient has arrived to the department and both the RN and LPN are involved in stabilizing this new arrival and discharging the previous patients as the lobby is now becoming congested with more patients seeking care. There is no mention of anyone suggesting that additional staff should be brought in to help with the load. During this time the pulse oximeter alarm fires off in Mr. B’s room showing at saturation of 85%. The LPN enters the room and resets the alarm and repeats a blood pressure, but there is no mention of the LPN assessing the patient’s respiratory and or mental status. At 16:43, almost forty minutes after Mr. B’s procedure had begun, the son who is at the bedside with him states the monitor is alarming. Nurse J finds a Mr. B in respiratory arrest and a stat code is called. A code team arrives and the patient is connected to a cardiac monitor for the first time. The patient is in ventricular fibrillation, CPR is begun, and according to this scenario he is intubated before he is defibrillated. After thirty minutes of interventions, this patient is resuscitated to a normal sinus rhythm with pulses, but is unable to breathe without a ventilator. He has fixed and dilated pupils and no spontaneous movements. Most likely due to the facility being a small rural hospital, they must transport this patient to a higher level of care, and he is flown out to another facility where the patient was ultimately determined to have brain death and was taken off of life support. A-1 Discuss the errors or hazards in the care in this scenario Causative factors in this scenario appear to include poor staffing to patient ratios, inadequate adherence to hospital policy for moderate sedation, and an obvious lack of communication between peers /coworkers. The human factors point to failure of staff to follow an established protocol, possible  fatigue, possible inability to focus on the task, and a lack of utilizing critical thinking skills. There did not appear to be any equipment problems other than the fact that the appropriate equipment that was available was not accessed. The environmental nature of emergency medicine lends itself to hazards in the fact that a department can go from being quiet and mellow in one moment, to being volatile and hectic the next moment. It is an environment of unpredictability and bestows care to a wider population of patients than any other department in the hospital. Common environmental issues to all emergency rooms can include poor location and accessibility of equipment, overhead paging systems that no one hears, security risks, lighting and space issues, lack of privacy due to patients being placed in hallways and other open areas not designated as patient care areas. Organizational factors may include budgeting limitations, staffing to patient ratios and contingency problems. Dealing with unexpected sick calls, inability to fill those calls, power outages and electronic documentation systems that fail, external environmental disasters, rapid influxes of unexpected patients and the media are all common factors that can disrupt hospital care. Well written policies are a must to guide staff in continuing to provide quality care while minimizing errors and hopefully avoiding sentinel events. Potential hazards and errors can be avoided by learning from the literature and past experiences of other emergency departments. Specific protocols for procedures performed in the ER are developed for this very reason. In the given scenario there is the issue of proper staffing which posed a hazard to the patient who eventually expired. Nurse to patient ratios in this scenario were inappropriate due to the fact that a patient who had received moderate sedation was not closely monitored and ideally should have received one on one nursing care for the duration of his procedure and until he met discharge criteria. This would have been possible had the RN asked for back up which was apparently available. Looking back on the scenario, it was noted that immediately after the joint reduction of Mr. B had been performed, a critically ill ambulance patient had arrived and the RN was responsible for that patient as well. In the emergency department, or any department for that matter, nurses are continually subject to frequent interruptions, the need to multi-task, and reliance on â€Å"work-arounds† because of inadequate systems  support. (Cherry & Jacob, 2011, p. 473) In the case of nurse J, she may have been fixated on completing other tasks, such as stabilizing the ambulance patient, thus distracting her from the ongoing developments with Mr. B. who appeared to be resting comfortably with his son at the bedside. Assuming the patient was safe with a family member, the RN missed the opportunity to reverse the downslide of events that unfolded. Not anticipating the need for additional help is a hazard when staff become overwhelmed but continue to proceed as if help is not needed, because they may be accustomed to being understaffed and working only with what they have. Therefore, this presents the issue of the culture of safety, or lack thereof. It did not appear that there was any organized culture of safety and the communication between staff members appeared to be minimal. Possibly there was an environment of distrust between coworkers, or an intimidating environment in which the RN was afraid to speak up to the ERMD regarding the management of the patient’s pain and sedation. Perhaps the LPN was intimidated by the RN and did not chose to inform the RN of the abnormal vital signs. It appears that inconsistent or absent communication skills among the staff present that day contributed overall to a hazardous situation. And lastly, possible poor training and education of staff creates a hazardous environment and the lack of critical thinking skills demonstrated in this scenario suggests that this is an area that needs to be examined closely at this hospital. There is no mention of what the LPN’s responsibility is in assessing the patient but it is difficult to comprehend how an experienced health care worker in an ER would not investigate a poor pulse oximetry reading further than simply resetting the monitor. Educational requirements and experience of the staff needs to be reviewed and revised by the interdisciplinary team as part of the improvement plan. Errors made in this scenario that contributed to this sentinel event include the fact that there was a specific protocol for conscious sedation and it was ignored. Although Nurse J was ACLS (advanced cardiac life support) certified, and she had completed the hospital’s training module, she did not follow the guidelines in the written protocol which more than likely would have prevented any of this event from happening. Perhaps she did not understand the protocol, perhaps she was accustomed to taking short cuts, or perhaps she was drug or alcohol  impaired. Another possibility is that the nurse was not able to find the online protocol on the hospital portal. Perhaps the portal was difficult to navigate and the policy was difficult to locate. Being under time constraint, a nurse might decide to forgo looking up the policy because it is too time consuming to look for it. Only Nurse J. would be able to provide us with this critical information. It is not clear as to why an experienced critical care nurse with no history of negligence did not follow proper procedure. Other errors include the fact that sufficient monitoring equipment was available and not utilized, including use of supplemental oxygen and possible end tidal CO2 monitoring. Furthermore, no one in the department called for any back up, such as a nursing supervisor or a respiratory therapist to help manage the patient. The ER physician who ordered the medications did not communicate with the nurse before the procedure about the risks associated with this patient, including the patient’s home use of opiates for his chronic pain. Polypharmacy, possible use of supplements, adherence issues, and the potential for adverse drug events all posed potential hazards that needed to be addressed. (Williams, 2002, ∂ 1) The RN did not question the physician about the orders and the physician in turn, did not question the nurse if she had any concerns. There was no â€Å"time-out† procedure performed by the staff, which would have given staff members the opportunity to voice concerns. The doctor also failed to notice that the patient was not being appropriately monitored, and along with the rest of the staff he did not appear to display a teamwork mentality. The key to a successful root cause analysis is to search for answers as to what system errors and failures need to be corrected, and not to pursue blame on any one individual. Individual blame centers around forgetfulness, inattention, or moral weakness. It is punitive. A systems approach examines the conditions under which health care workers work and sets up defenses to avert errors or mitigate their effects. (Cherry & Jacob, 2011, p. 473) The goal is to bring staff together to design and implement processes that provide uniform standards of treatment and care and provide safety to all involved and minimize the likelihood of harm or a sentinel event. B. Improvement Plan By requiring the staff of the emergency department to reexamine its actions on that day, a dialogue is created that hopefully will create a strong motivation to seek out better and newer ways to handle patients that require sedation and monitoring. If the participation is not there, then the motivation will not be created and change will not occur. One way of developing an improvement plan would be to apply the theories of change developed by physicist and social scientist Kurt Lewin in the 1950s. His change management model, known as Unfreeze-Change-Refreeze, refers to a three stage process of transitioning through change. Lewin believed that to begin any successful change process, one must first understand why the change must take place, and this is where the motivation for change begins. He stated that one must be helped to re-examine many cherished assumptions about oneself and one’s relations to others. This is the stage known as â€Å"unfreezing†. (Thompson, n.d., p. 1) In the case of the emergency department, the entire team needs to be compelled to change the way sedation procedures are performed, as well as how patients are handled before and after the procedure. In addition to reviewing the procedural sedation protocol, the team needs to look at overall hospital care of those receiving any medications that cause respiratory depression. This should not be too difficult to promote since the procedure performed that fateful day resulted in harm and subsequent death of a patient. Not only was the patient and his family harmed, the entire organization was harmed and is liable for this incident. The hospital and its emergency department’s community reputation is going to suffer. Knowing that the staff that day is probably emotionally traumatized and possibly fearful of the consequences, the environment is ripe for change and the unfreezing stage can begin with a review of the sedation policy and why it was not followed. Each individual there and staff that were not there that day need to be made aware and can meet one on one with the department manager to voice their concerns and questions. Barriers hopefully will be identified as to why the sedation protocol was not followed that day. The hospital already provides an electronic educational module on conscious sedation procedures which would have a required date for staff to complete. This module should be reviewed for any inconsistencies  and updated and it should be made easily accessible on the computer portal. The actual written policy should also be easily accessible on the portal as well as in print form in a binder at the nurses station, should staff not have access to the computer. An analgesic protocol could be developed in which there would be a minimum time lapse between opioid doses (for instance 10 minutes versus 5) and the use of a hospital approved sedation scoring system should be in place. Patients in addition to requiring continuous pulse-oximetry monitoring should also be on continuous end tidal CO2 monitoring as well, long considered a more effective way of measuring effective ventilatory status. A new electronic training module on the use of end tidal CO2 monitoring would be mandatory for nursing staff to complete and equipment in the ED would be upgraded to provide for this type of monitoring. A representative could come and demonstrate the use of this type of monitoring and sign off employees for a mini-education module. Although many emergency departments have upgraded their documentation to all electronic, it might be helpful for staff nurses who are continuously monitoring patients at the bedside to use paper forms to document the pre procedure requirements including consents, time-outs, intra procedure medications and response to those meds and vital signs as well as post procedure Aldrete scores and recovery notes. This would be advantageous for simply the reason that not every bed has access to a computer. Health care providers certified in Advanced Cardiac Life Support (ACLS) must be in direct attendance with the patient throughout the entire course of the sedation and until the patient is fully recovered. Their primary responsibility is to monitor the vital signs including heart rate and rhythm, blood pressures, respiratory rate and oxygen saturation, as well as the patency of the patient’s airway. The RN managing the patient should never leave the patient unattended or engage in tasks that would compromise this continuous monitoring. The RN is responsible for taking the leading role in assuring that the care provided is safe. Proper airway equipment and drug reversal agents should be at the bedside and this must be documented. In order to unfreeze the staff and help them to change their behaviors, the ED could hold mock sedation procedures to practice their skills in managing a sedated patient. Annual skills days should be held with  review of the policy and equipment used. Staff would be signed off annually on this module. Certifications for BLS(basic life support), ACLS, PALS(pediatric advanced life support) and possibly TNCC (trauma nurse core curriculum), should be up to date and the hospital should offer these courses on campus to make it easier for their employees to maintain their certifications. Staff members whose scope of practice do not require them to practice ACLS or PALS should be reeducated on what normal vital signs are, how to set parameters on the cardiac monitors, how to take vital signs on the cardiac monitor and they need to review basic BLS skills by attending their own skills day. Teaching should include basics on what normal vital signs are for different age groups, and how medications can alter these vital signs. If the hospital has the funds to open a simulation lab, all nurses and allied health personal could practice simulated scenarios on mannequins and even videotape them. This would be a huge asset for the staff of all the patient care departments. Another part of the improvement plan would include classes for staff on communication and critical conversations. Learning how to communicate as a team and voice concerns about patient safety is a skill that requires practice, confidence and no fear of retribution or intimidation. Staff members who deal in stressful and hectic environments may at times be uncertain when they see behaviors that are unsafe and therefore may elect to say nothing when they believe the care of a patient may be compromised. In the case of the LPN who turned off the SPO2 alarm, I would wonder if perhaps there was a communication barrier between her and the RN and or the MD, or was it simply a knowledge deficit. An action plan needs to be in place for a saturated emergency department in which additional staff can be called in with a less than 30 minute wait time, or perhaps float other available qualified staff from other departments, such as the critical care unit or the telemetry floor. Because critical care nurses are accustomed to working in a 1:1 environment with their patients, it would have been ideal to float a CCU nurse to the department when Nurse J realized she could not take care of the rest of the department without leaving Mr. B unattended. Of course this may not have  been feasible since we do not know the census in the CCU. Chart reviews are also an invaluable tool for improvement. The manager will assign nurse in the ED to perform a monthly audit of all sedation charts with checklists of what was done correctly and what was not. These audits are important for providing data on how the ED needs to improve its performance and safety measures. This data will be provided not only at ED staff meetings but at quality improvement meetings involving the nursing director and hospital administration. If there is a problem convincing the hospital to provide safe staffing levels, the ED must provide strong data in order to show administration that there is a need to provide additional nursing. After the uncertainty of the unfreeze stage has occurred, change then begins to take place. Staff will start to believe and act in ways that support the new growth of the department. The transition will not happen rapidly as people take time to learn and embrace new ways of doing things and for each individual the rate of change is personal. In order to accept the new change and contribute to its success, staff will need to understand how the changes will benefit them and not every person will feel this way. Most healthcare workers probably feel that if healthcare delivery is made safer and better for their patients, then they will buy in to the need for changes and produce those changes. Unfortunately some of these people may feel harmed by change, and it is possible to notice some folks not participating in meetings, outside events, or educational updates. They may voice discontent with the whole process and complain that the changes are unnecessary. They may feel the status quo is being challenged and are threatened if they are unable to adapt to the changes. They may eventually leave the department or even the hospital environment as a whole. These are the people who may require the most encouragement and handholding to get them through the transition. Time and communication are of utmost importance and as staff gains understanding of the changes, they also need to feel connectedness to the organization throughout the transition period. (Thompson, n.d., p. 3) Lewin’s third stage of change, or Refreezing, takes place when the organization has identified the barriers to sustain the changes made, and when it has identified what makes the changes work. Employees feel  confident and comfortable using new communication techniques, they participated in learning the new procedures and feel supported by their peers and leadership. There is an established feedback system for employees to participate in regarding their education and training, in which they can voice what works and what doesn’t. Changes are now used all of the time and are incorporated into the normal day to day operations in the ED. If the changes are not used regularly and not anchored in to the culture of the ED, the refreezing state cannot occur and employees may get caught in a â€Å"transition state† where each person is not sure how things should be done and there is no consistency for policies and procedures being followed. For the refreezing states to be successful, the department should celebrate its success with the change. Employees will need to have a sense of closure and management needs to help them feel appreciated for enduring an uncertain and uncomfortable time. It is important to encourage staff to believe that the contributions they have made have made the changes a success. (Thompson, n.d., p. 4) Continuing to provide support and transparency keeps employees informed and motivated to preserve the new changes in place. Allowing staff to voice their opinions and participate in how changes are rolled out is part of this process. Overall, a team approach to care is of utmost importance in the ED and each individual should be encouraged and reminded regularly how important their contributions are to the whole. Reward systems to encourage pride and enthusiasm for work well done can be included at monthly staff meetings. One or two employees might receive a gift or a trophy for hard work, these recipients would be nominated by their peers who anonymously write a nice note about someone who did something nice for a patient or a staff member or just did a particularly great job that day. Team building activities can also include an organized activity outside of the ED where employees and their family members can socialize together and relax. Nursing leaders and managers should strive to build environments that are conducive to friendships, facilitating and promoting good communication and respectful communication between nurses, physicians and administrators. (Blosky & Spegman, 2015, p. 34) Trust is the cornerstone of good communication, which was sorely lacking in the ED that day. C. Use a failure mode and effects analysis to project the likelihood that the  process improvement plan you suggest would not fail. (Identify the members of the interdisciplinary team who will be included in the RCAS and the FMEA) FMEA is a step by step process used to identify all possible failures in a design , a manufacturing or assembly process or a product or a service. FMEA was started by the US military in the 1940s, and was further developed by the aerospace and automotive industries. (American Society for Quality [ASQ], n.d., p. 1) It has been adopted by the healthcare industry successfully as a tool to identify areas of healthcare processes tat may fail, in order to prevent harm or sentinel events before they occur. â€Å"Failure modes† are the ways, or modes in which something may fail. Failures are errors or hazards, which affect the customer and in healthcare the customer is usually the patient. These errors or hazards can be actual, or potential. Effects analysis is the study of consequences of those failures. Failures are prioritized in order of how severe the consequences are, their frequency of occurrence, and their ease of detection. The purpose of the FMEA is to eliminate or reduce the percentage of failures, starting with the highest priority areas. (ASQ, n.d., p. 1) In the scenario of Mr. B, unfortunately the FMEA cannot change the outcome, but it will be a proactive method of developing a new policy and procedure for how sedation cases are handled in the emergency room setting. The FMEA will be used to evaluate the new protocol for sedation procedures as well as staffing protocols related to monitoring 1:1 patients. This evaluation will occur before the actual implementation and will be used to assess its impact on the existing protocols.(IHI, 2015, p. 1) The process that needs to be evaluated and improved specifically to the case of Mr. B, would be the moderate sedation policy and its specifics to requirements of staff during the procedure and the recovery period. Some of the failure modes that may occur or have the potential to occur would be staff resistance to change, inexperienced nurses or practitioners with lack of education, inadequate ability to staff the ED appropriately during influx of patients, sick calls, or inadequate equipment or equipment failure. (Study Mode, 2014, p. 12) The key to a successful FMEA will be the involvement of a interdisciplinary  team, which would most likely consist of the some of the same members of the RCA. An emergency room physician, preferably the director, director of respiratory therapy, the hospital pharmacist, the ED nursing director, a risk manager, a head administrator who can lead the group in decision making, one or two ACLS certified staff nurses from the ED that perform sedation procedures, head of anesthesiology, and possibly even members from other departments where moderate sedation is performed. The team will need to meet regularly and be committed to providing continuing support during the course of implementation. C1: Interventions With the unfortunate scenario of Mr.B, it is now up the the interdisciplinary team to begin testing interventions that will or may be integrated in to the new plan for management of moderate sedation patients, with the goal of improving safety and eliminating adverse events. Once the established team has focused their aim, their next step would be to test a change or a few changes in the ED. This would be done with subsequent procedural sedation procedures which are commonplace in the ED. A small but major change to test would be the mandatory presence of an ACLS certified RN in 1:1 care of the patient from the beginning of the procedure and throughout it to discharge. The goal of this change is to prevent adverse events from respiratory depression in 100% of all patients receiving sedation in the following 6 month period. Performing this test several times will enable the team to see if the staff is actually complying with the new protocol and what barriers there are to prevent it from being successful. Staff will give feedback later as to what is working and what is not, and what they think needs to be done to make the changes work. An effective way to implement testing would be to utilize a PDSA cycle. The Plan-Do-Study-Act (PDSA) cycle is known as shorthand for testing a change by planning it, trying it, observing the results, and acting on what is learned. (Institute for Healthcare Improvement [IHI], 2015, p. 1) According to the Institute for Healthcare Improvement, the reasons to teats changes are as follows: To increase ones belief that the changes will result in improvement To decide which of several proposed changes will lead to the  desired improvement To evaluate how much improvement can be expected from the change To decide whether the proposed change will work in the actual environment To decide which combinations of changes will have the desired effects on the important measures of quality To evaluate costs, social impact, and side effects from a proposed change To minimize resistance upon implementation The Institute for Health Improvement lists these steps in the PDSA cycle to include: Step 1: Plan Plan the test or observation, including a plan to collect the data State the objective of the test: â€Å"Minimize or eliminate adverse events from respiratory depression while being monitored in the ED under conscious sedation† Make predictions about what will happen and why Develop a plan to test the change (Who, what, when where? What data needs to be collected?) Step 2: Do Try out the test on a small scale: maybe only perform the test in a 3 week period, on sedation procedures performed between the busiest times of the ED, for example between noon to 6pm. In a 6 bed rural ED, this might actually be the busiest time period. Carry out the test Document problems and observations, unexpected and expected Begin analysis of the data Step 3: Study Set aside time to analyze the data and study the results, for example: a biweekly or monthly meeting of the FMEA team. Complete the analysis of the data Summarize and reflect on what was learned Step 4: Act Refine the change, based on what was learned from the test. Determine what modifications should be made. Prepare a plan for next test, probably on a larger scale. For example, test all sedations over a month , for actual 24 hour periods in the ED. In addition to performing the PDSA cycles, the ED could appoint a volunteer or volunteers from the department to form a safety committee with a leader being the liaison who would have the authority to come up with quick solutions to certain problems that are encountered in the department on a daily basis. The liaison would take care of fixing broken equipment or replacing it, ordering new equipment and providing user training, communicating with staff about safety concerns and bringing these concerns to management and the FMEA team. The safety liaison would be trained in Human Factors Engineering, the science of why people make mistakes. The staff will need to be reassured that this person is their ally and not an informant or disciplinarian. (Institute for Healthcare Improvement [IHI], 2015, ∂ 1) This is a person they should feel comfortable reporting their concerns to. This person could take an active role in the PDSA testing and collect data as which could be added to the monthly chart audits of all the conscious sedation procedures performed since that fateful day with Mr. B. C2: Presteps: Discuss the pre-steps for preparing for the FMEA. Step one in preparing for the FMEA in regards to revising the sedation protocol involves selecting a specific process to evaluate. While there were many factors that contributed overall to the sentinel event that occurred , the FMEA should be focused on a sub process. Conducting an FMEA on a combination of the sedation protocol, the staffing ratio issues, the communication problems between staff members, knowledge deficits of staff and equipment issues would be an overwhelming task, so instead we will consider individual analysis of each variant. In this case, we are going to focus on creating a better defined policy on how to safely perform conscious sedation in the emergency room setting in order to prevent further sentinel events. We want to define in the policy what licensed and certified personnel is to be present and performing the procedure, and step by step spell out what is required of those team members from the time of informed consent to the time the patient is discharged from the ED. The policy needs to be easily accessible and there needs to be a standard way of making sure staff has read the policy and understands how to follow it. The goal is to make sure that the patient has 1:1 care at all times with qualified  personnel and leaves the ED in stable, improved condition. The second pre-step is to recruit the multidisciplinary team, including everyone who is involved at any point in the process. Be clear that not all people need to be included on the team throughout the entire process, but should be part of the discussions in which they are or did participate in the process. For example, In the case o f Mr. B, radiology was probably at the bedside performing pre and post reduction films, in which the RN clearly would not have remained at the bedside unless he or she was wearing a lead apron. Pharmacy may have become involved if they had to mix any post resuscitation drips for the patient after he returned to a sinus rhythm from ventricular fibrillation. The secretary was involved in calling a rapid response team, and members of that team may be able to provide valuable insight as well. The third pre-step is to have the team meet together to create a list of all of the steps in the process. Every step should be numbered and be as detailed as possible. Note that this may take numerous meetings to complete this portion, due to all of the variables and complexities. Using flowcharts helps team members to visualize the processes more clearly and create a more understandable outline of the steps. There needs to be a group consensus that the outlined steps of the FMEA correctly show the process. By creating a step by step flow sheet the team will be able to visualize the scenario in detail and begin the process of elimination of what does and does not work and move on to pre-step 4. The team will now begin to list all of the possible failure modes. Possible failure modes include absolutely anything that could go wrong, such as the following: Staff not trained in protocol Staff not knowing how to properly use equipment Monitor not connected to patient Equipment not plugged in Medications not reconciled Communication problems between peers Assessments not completed Ancillary staff not educated IV fluids not running Patient experienced respiratory arrest These are just of the few of the possible failure modes that could be listed. For each of these failure modes, the team must list a cause. For example, in the case of Mr. B, he was never connected to a cardiac monitor until he went unresponsive, so the team must try and explain the cause of this. Prestep #5 , for each failure mode, the team will need to assign a numeric value which is called the Risk Priority Number or RPN. The RPN is a measurementof three variables: the likelihood of the failure occurring, of it being detected, and its severity. This is a scoring method that assists the team in determining what areas need the most most focus on improvement. C3 Three Steps: Once again, assigning numeric values to three separate variables assists the team in determining the issues which should be prioritized in order of importance, or the need for improvement. The three topics are as follows:( IHI, 2015, p. 4) the likelihood of occurrence: In other words, how likely is it that this failure mode will happen† A score between 1 and 10, with 1 meaning â€Å"very unlikely to occur† and 10 being â€Å"very likely to occur†. In the case of Mr. B, had a FMEA already been in place prior to his visit to the ED, the likelihood of his demise would have been much more unlikely to occur. But the system had failed him and due to all of the multiple mistakes that did occur that day, the likelihood of what happened was higher up on the numeric scale. the likelihood of detection: If this failure mode does happen, how likely is it that it will be detected? † A score between 1 and 10, with 1 meaning â€Å"very likely to be detected† and 10 being â€Å"very unlikely to be detected.† On the day of Mr. B’s demise, there were multiple opportunities for the staff to detect that there was a potential problem, but they did not. No one noted the lack of staff, communication was poor, and proper equipment was not utilized. So, this question goes back to the Root Cause Analysis and in the FMEA the team will need to determine how the staff can detect these failures before harm occurs again to someone else. the severity: If the failure mode happens, what is the likelihood that the patient will be harmed? † A score between 1 and 10, with 1 meaning â€Å"very unlikely that harm will occur† and 10 being â€Å"very likely that severe harm will occur†. According to the IHI, a score of 10 often means death. In Mr. B’s case, the consequence that resulted from the  failures in the ED that day was his untimely death. So the severity rating for that particular day would be a 10. D. Discuss how the professional nurse may function as a leader in promoting quality care and influencing quality improvement activities: The professional nurse plays a critical role in hospital quality improvement, since nurses are the primary caregivers in the system of healthcare. They are pivotal in improving the processes in which care is provided. According to Cynthia Barnard, MBA, the role of the professional nurse in quality improvement is two-fold: to carry out interdisciplinary processes to meet organizational QI goals, as well as measuring, improving and controlling nursing sensitive indicators affecting patient outcomes specific to nursing practices. She states that all levels of nurses, from the direct care at the bedside, to the chief nursing officer (CNO), play a part in promoting QI within the healthcare provider organization. (HCpro, 2010, p. 1) Ms. Barnard lists the following levels of nursing and their professional responsibilities: The CNO: The CNO sets the tone for the nursing departments participation in QI. As an administrator, the CNO is responsible for integrating nursing practices in to the organizational goals for excellence in patient outcomes by communicating the strategic goals to all the levels of staff. The nurse manager (NM) or nursing director: The NM or director is responsible for communicating and operationalizing the organization’s QI goals and processes to the bedside nurse. The NM identifies specific nursing sensitive indicators that need improvement according to the organization’s specific patient population and coordinates QI processes to improve these at the unit level. The direct care nurse: The bedside nurse is the key to quality patient outcomes, carrying out the protocols and standards of care shown by evidence to improve patient care. Important to this provision of quality care is the fact that professional nursing leaders are the key factor in setting the tone and providing an environment in which all health care staff feel empowered to uphold these expectations. If nursing leadership and administration feel that they have less than adequate engagement of staff, it may be simply because the staff may not always understand the rationale and momentum  behind particular quality improvement initiatives. For nurses to be involved in delivering high quality care, it is imperative that leadership allows the participation of staff nurses into the design and implementation of processes by continuously educating and informing them, instead of simply telling nurses what they are supposed to do. A hospital culture that encourages quality as everyone’s responsibility is most likely to achieve sustained and noticeable improvement. Because nursing practice occurs in the context of a larger team, the impact of other departments and practitioners must be included in leadership’s efforts to improve quality. (Draper, Felland, Liebhaber, & Melichar, 2008, p. 4) By having every staff member engaged, including the other members of clinical staff, ie; physicans, respiratory therapy, even housekeeping and dietary management, accountability for patient safety and quality becomes a group effort and does not rest mainly on the shoulders of the nursing population. References American Society for Quality (n.d.). Failure Mode Effects Analysis (FMEA). Retrieved July 3, 2015, from http://asq.org/learn-about-quality/process-analysis-tools/overview/fmea.html Blosky, M. A., & Spegman, A. (2015). Communication and a healthy work environment. Nursing Management, 46(6), 32-38. Cherry, B., & Jacob, S. R. (2011). Contemporary nursing; issues, trends and management. Available from https://online.vitalsource.com/#/books/978-0-323-06953-3/pages/52165015 Draper, D. A., Felland, L. E., Liebhaber, A., & Melichar, L. (2008). The rrole of nurses in hospital quality improvement. Retrieved July 3, 2015, from http://www.hschange.org/CONTENT/972 Frain, J., Murphy, D., Dash, G., & Kassai, M. (n.d.). . Retrieved, from Galley, M. (n.d.). Basic elements of a comprehensive root cause investigation; three steps and three tools that organize and improve your problem solving capability. Retrieved June 29, 2015, from rootcauseanalysis.info HCpro (2010). Ask the expert: Understanding nur sing roles in quality improvement. Retrieved July 6, 2015, from www.hcpro.com/NRS-248978-868/Ask-the-expert-Understanding-nursing-roles-in-quality-improvment.html Institute for Healthcare Improvement (2015). Failure modes and effects analysis. Retrieved July 3, 2015, from