Essay RTT Role of Organizations

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Organizational Systems

This paper is the analysis of the avoidable sentinel event of Mr. B, a sixty-seven year old patient who was admitted to the emergency room with left leg and hip pain following a fall. A root cause analysis will help identify key elements which led to the unfortunate event. A plan of action to develop a change theory will help formulate an improvement plan to prevent future occurences like that of Mr. B. A failure
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The nurse and ER doctor failed to recognize how the medications react by relaxing the skeletal muscles, compromising Mr. B's lung expansion. Since Mr. B could not walk around to expand his lungs, he could have benefited from bronchodilator treatments or supplemental oxygen. When the LPN addressed the low oxygen alarm by resetting the alarm and leaving the room, she neglected to assess Mr. B and failed to perform her duties as a nurse.
Change Theory The employees, such as Nurse J and the LPN need to be advised that they did not adequatley carefor Mr B by not assessing him properly upon his arrival, and not calling the respiratory department for additional help when his respiratory status was in question. Informing the LPN that she failed to assess and care for her patient when the low oxygen alarm was set off would be unacceptable in the employee's performance. Clear warnings to correct their performance deficiencies will result in adverse consequences. Identifying the problem or the skill the employee lacks in by being specific will help address the problem. An established expectation would be defined in the area of performance that needs to be changed with a clear list in writing. A deadline that is reasonable between the supervisor and the employee needs to written and agreed upon. Resources that the employee may need such as

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