Organizational Systems-Wgu-Task 2

The goal of this paper is to scrutinize the regrettable sentinel event of Mr. B, a sixty-seven-year-old patient who was admitted to a rural ED with left leg pain that he found unbearable. A root cause analysis will be used to exam the causative factors that led to this unfortunate sentinel event. Then I will identify the errors or hazards in the care of Mr. B. A change theory will then be utilized to establish a useful improvement plan that would hopefully decrease the chances of a repeat of the outcome in the Mr. B scenario.  A Failure Modes and Effects Analysis (FMEA) will then be

A) There are several issues in the case of Mr. J that need to be examined. Using nurse sensitive indicators “reflect patient outcomes that are determined to be nursingsensitive because they depend on the quality or quantity of nursing care” (American Sentinel University, 2011). Mr. J. was not receiving acceptable care, because his daughter noticed a red, depressed area over Mr. J’s lower spine, similar to a severe sunburn. This skin condition is the first stage of a developing pressure ulcer. a. Nurses should be aware that a patient with limited mobility is at risk for skin breakdown, and pressure ulcers.

Meanwhile, elsewhere in Habersham County, Tom was feeling slightly nervous as he exited the staff lounge and entered the hustle and bustle of County Hospital’s ER to begin his first shift as an RN. The first few hours of his shift passed slowly as Tom mostly checked vital signs and listened to patients complain about various aches, pains, coughs, and sniffles. He realized that the attending physician, Dr. Greene, who was rather “old school” in general about how he interacted with nursing staff, wanted to start him out slowly. Tom knew, though, that the paramedics could bring in a trauma patient at any time.

To do so, I am going to use the fishbone diagram to categorize the causative factors (Potter & Perry, 2008).   For patient characteristics, Mr. B was a 67 year old patient with routine use of oxycodone to treat chronic pain.  Because of his routine use of oxycodone, he may need a different dose to get to a sedated level than other people who are not on any medication.  Next is the task factors, the hospital had a policy which requires that anyone who are treated with moderate sedation or analgesia have to be put on continuous blood pressure, ECG, and pulse oximeter monitoring until the procedure is done and patient is in stable condition.  Mr. B was not being monitored accordingly during the sedation process.  Another task factors is that all staffs must first complete a training module on sedation before performing the task.  Individual staff is a factor too, Nurse J had completed the training module on sedation, he had an ACLS certification as well as experience working as a critical care nurse.  Team factors include communication between staffs; an example would be the LPN not informing Nurse J or Dr. T when the alarm went off the first time, it showed that Mr. B had low oxygen saturation.  Work environment factors included the staffing in the ER, the equipments they had, and the level of experience of the staffs.  According to the scenario, additional staffs were available for back up support and all the equipment needed

The Utah Symphony and the Utah Opera have combined into one company. Anne Ewers is the new leader of the combined companies. This paper will help her in the development of a new strategy to look at the success of the merge. The Utah Symphony is a group II orchestra. This is based on the level of expenditures every year. In the year of 2001-2002 the average expenses were around 8.8 million for group II orchestras. The Symphony spend around $12.2 million for that year. The Utah Symphony was in the top orchestras in the United States. Even though the symphony had a lot of money the financial state was declining. The musicians were part of a union. They were negotiating their

A root cause analysis (RCA) is an essential tool that can be used to examine and understand the ways in which systems fail as well as discuss those specific failures that led to a specific adverse event and potentially implement steps or behaviors to prevent that event from happening in the future (Ogrinc & Huber, 2013). In the case study presented, a number of system failures may have contributed to the patient outcome. As such, an RCA of the case study would help determine those specific

A root cause analysis (RCA) is a method by which we can examine a serious adverse event and identify the cause, or causes, that led up to the event. Although personnel are involved in these events, the primary purpose of the RCA is to identify the cause, not to assign blame (Agency for Healthcare Research and Quality, 2014). It is through identifying a cause, or causes, of an adverse event that we can improve on patient care processes and thereby patient safety. The RCA is designed as a specific protocol that starts with data collection looking at the sequence of events that led to the

This following will outline my personal leadership practices and potential future leadership. To analyze my leadership qualities I will use the Seven Habits Profile and a leadership theory to determine my strengths, weaknesses, and areas of opportunity for improvement. In conclusion, I will determine the best recommendations for long-term improvement as well as SMART goals, or short-term courses of action, for leadership improvement.

By understanding nursing sensitive indicators, the nurses in this case could improve the structure, process, and outcomes of their nursing care. The structure of nursing care is indicated by the supply of nursing staff and the skill level of the nursing staff. By the nurses having increased knowledge of the issues hip fracture patients are prone to having, such as decrease mobility, increase need for surgical intervention, and increase risk of falls, could help improve the quality of patient care. A patient with decrease mobility is at higher risk for pressure sores. The nurses in this case may have prevented the one by proper

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

The hospital acquiring data on the above indicators of pressure ulcer incidence, prevalence of restraints,

Chosen for root cause analysis is case study number 18, titled “Not for IV Use: The Story of an Enteral Tubing Misconnection” from the book Case Studies in Patient Safety: Foundations for Core Competencies. Root cause analysis is a process whereby error producing system factors are identified and reviewed to assist in the formatting and implementation of solutions to prevent similar errors from reoccurrence (Wachter, 2012). This accounting of the patient’s experience located in the Systems-Based Practice (SBP) section also highlights various code of ethics violations such as autonomy, beneficence, nonmalfeasance, and veracity. The SBP approach in healthcare requires that personnel recognize how patient care connects to the entire health care system and how to utilize successfully system resources to improve both quality and patient safety. There are specific core competencies that assist with this process. Some of which include the ability to work effectively in the delivery-care setting, perform responsibilities according to role, ability, and qualification, advocate for quality patient care and resources, and participate in error identification and solution implementation (Johnson, Haskell, & Branch, 2016). This patient’s story demonstrates an apparent failure of these core competencies.

As a school we are required to have policies and procedures for all the staff/adults and

Does the compliance with a sedation protocol improve after nurses receive a sedation competency over a three month period? The available data supported the hypothesis that nursing education and competency can lead to consistent best practices and positive outcomes for patients. The answers to this research question can help develop interventions that support best practices for patients who are mechanically ventilated and receiving intravenous sedation.

Neither staff member identified the downward trending of the patients available vital signs and did not evaluate consciousness of the patient. Failure to assess appropriately and recognize deterioration of the patient resulted in a prolonged period of time in which the patient was not adequately oxygenated. Research has shown that short staffing, with decreased nurse to patient ratio, has been found to be associated with increased mortality (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Joint Commission on Accreditation of Healthcare Organizations, 2005; Needleman, Buerhaus, PKankratz, Leibson, Stevens, & Harris, 2011). This reinforces the need to match staffing with patient census, acuity, and need for nursing care.