Mr B Root Cause

1725 Words May 1st, 2015 7 Pages
RTT1 Organizational Systems Task 2
The purpose of this paper is to analyze the unfortunate sentinel event of Mr. B, a sixty-seven-year-old patient presenting with severe left leg pain at the emergency room. A root cause analysis is necessary to investigate the causative factors that led to the sentinel event. The errors or hazards in care in the Mr. B scenario will be identified. Change theory will be utilized to develop an appropriate improvement plan to decrease the likelihood of a reoccurrence of the outcome of the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA) will be used to project the likelihood that the suggested improvement plan would not fail. Lastly, key roles nurses would play in improving the quality of care
…show more content…
B’s tolerance to opiates not considered, Mr. B.’s clinical situation not considered (i.e., Mr. B’s age and renal function), and knowledge deficit of opiates. Drilling down the data to identify the root cause of Mr. B’s death is the fifth step in conducting a RCA on Mr. B’s sentinel event. Upon analyzing the data, causative factors, and events leading to Mr. B’s sentinel event, the RCA team determined that the root cause of Mr. B’s death is a medication error. Mr. B was given an overdose of hydromorphone. The final step in a root cause analysis is to implement changes that will mitigate the root cause. Changes include educating the nursing staff about hydromorphone, such as side effects and adverse reactions, A1. Errors or Hazards
There are errors and hazards in care that occurred in the Mr. B scenario. One error was the emergency room physician’s failure to recognize the signs and symptoms of deep vein thrombosis (DVT) that Mr. B was presenting. If not treated early, a DVT can become a pulmonary embolism, a fatal condition that Mr. B unfortunately developed. Another error in care that happened in the Mr. B scenario is the nurses’ failure to monitor Mr. B’s ECG and respirations. Early detection of critical ECG and respiratory changes could have initiated medical interventions that would have saved Mr. B’s life. One hazard is the emergency room nurses’ heavy patient load at the time of Mr. B’s sentinel event. Another hazard is having a licensed