A Root Cause Analysis ( Rca )

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Root Cause Analysis
A root cause analysis (RCA) must be conducted when a sentinel event occurs in order to identify where the systems and pro cesses involved failed and how these systems may be improved to eliminate or reduce the risk for a reoccurring event of this type
, 2011
first step in conducting a root cause analysis is to form a committee of individuals that are from different levels of t he organization to review the failures of the system and processes that are associated to the event. This allows the committee to implement appropriate changes if necessary to the system and process to reduce the risk of a future ev ent of this nature havi ng .
Based on the scenario provided
Mr. B arrived at the hospital with a
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A1. Errors or Hazards
In the scenario provided the following are errors that led to the un fortunate outcome.
h e l ack of proper staffing and a radiology study to confirm that Mr. B did not have any fractures prior to the reduction procedure may have contributed to his death
A s Mr. B could have had internal bleeding from a fractured pelvis or femur that w ent undetected
The ED physician’s medication dosages were unsafe and the re
administration times increase d the risk of harm to the Mr. B.
The lack of knowledge or communication betwee n Nurse J and the ED physician in regard to the medication dosages and re
administration times led to the over sedation of Mr. B
The scenario d oes not confirm that
Nurse J or th e
physician had successfully completed the training module for conscious sedation required by the hospital where they worked
Nurse J and the ED physician failed to follo w the policy in regard to a dministeri ng c onscious sedation to Mr. B
Nurse J and the LPN failed to call for a respiratory therapist to be present d uring a conscious s edation procedure.
; n or did anyone in the emergency
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