Health Care and Emergency Transport Patient Essay

1145 WordsNov 3, 20135 Pages
Root Cause Analysis It is important to evaluate all aspects of the sentinel event as well as the events that led up to Mr. Bs death. The questions that follow are pertinent because they set up a scenario with valid questions that need to be answered. The goal is to identify errors and prevent reoccurrences incident in the future. In the case study, it appears that a lack of protocols as well as a lack of communication amongst staff members may have been contributing factors which led to death of a patient in the emergency department. In carrying out a root cause analysis, it is helpful to re-create the event with the staff members integrated in the event. Members of…show more content…
Change Theory According to (Mitchell,2013)change theories are similar problem-solving approaches to implementing planned change. In the incident of Mr. B. following change theory is utilized practicing Lappets theory. Assessment Nurse B makes a detailed assessment of the Mr. B that includes biographical details, relevant clinical history, social details and medical observations. This phase is normally taken into consideration throughout a patient’s hospital stay. Planning Following assessment, the nurse b collaborates with the patient, significant other or family member and multidisciplinary team wherever possible to determine how to address the needs of the patient. Implementation This phase relates to the nurse carrying out and documenting the care previously greed at the planning stage. Post administration of sedations followed by a protocol which would closely monitor patients vital signs. Nurse B continues to monitor the patient throughout the emergency room visit shift. The vital signs are monitored every 15 minutes and documented. Parameters are set instituting intervention if pulse oxygenation falls below 95%.  Evaluation The evaluation phase all interdisciplinary team members and their part in the interaction of patient care. Assessments graded for what worked well
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