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.
Root cause analysis process will utilize a systematic step-by-step approach to help identify all causative factors leading to this sentinel event. The main purpose of the Root Cause Analysis is to understand how the event happened, why did it happen, and what can be done to prevent an event from happening again. The first step, collect all necessary data associated with this event such as: current policy and procedures, incident report, Mr. B’s health history, environmental flowcharts, dispensed medications, equipment and staffing factors relevant to the event. The process of identifying causative factors can begin once all the data is collected. The goal, of a Root Cause Analysis, is to identify interventions to prevent an event from reoccurring.
We then look at the errors of hazards that occurred in the Mr. B scenario. Though we can say understaffing may have contributed to Mr. B’s demise, we cannot blame understaffing. This scenario is regrettably connected to inattentive nursing practice. It is clear that respiratory therapist was in the building and
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
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 discharge criteria in the policy states the patient will be fully awake, vital signs stable, no nausea or vomiting, and the patient is able to void. All practitioners that provide moderate sedation must complete a training module prior to providing moderate sedation, this includes personnel assisting with the procedure. The first process failure was not meeting the required monitoring of the patient as mandated by the moderate sedation policy. In the absence of ECG or respiratory monitoring the sedation administered produced apnea then asystole without ED personnel being aware of acute changes in the patient’s condition. There is no explanation for why the patient was not on continuous ECG monitoring. Equipment was found to be in good working order.
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
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
In the root cause analysis, the root cause analysis team investigates the role of multiple factors that could have contributed to the event, such as communication, equipment failures, staffing levels and/or fatigue, training, policies/procedures, and organizational culture. Following the analysis, the facility must implement a corrective action plan to implement the findings of the analysis or at least report to the appropriate state department any reasons for not taking a corrective action plan. The findings of the root cause analysis and a copy of the corrective action plan must be filed with the commissioner within 60 days of the event for the State of Minnesota. The team of clinical and quality improvement experts review the root cause analysis and corrective plan meet all criteria and that the facility is able to take steps to reduce this risk of any future adverse events. The review team will provide feedback to the facility and allow modifications to be applied until all criteria have been met. Each event can go through up to three reviews (Minnesota Department of Health,
A1. The Utah Symphony was recognized as a Group II orchestra. Group I and Group II are distinguished by the endowment amount and level of annual expenditures. For the year of 2001-2002, the average endowment for Group I orchestras was around $76 million and $8.8 million for Group II orchestras. The Utah Symphony came in just shy of $12.2 million in 2000-2001 and was projected to be upwards of $13.7 million for 2001-2002. That being said, the Utah Symphony was considered to be at the top end of Group II symphony orchestras in the United States (Ager & Delong, 2005). However, even with these strengths within the symphony, prior to the proposed merger of the two organizations, the Utah
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.