RTT1 Task 2 Essay example

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RTT1 Task 2 Organizational Systems and Quality Leadership Western Governors University Leslie Baylor A. Complete a root cause analysis (RCA) that takes into consideration causative factors that led to the sentinel event (this patient’s outcome). “A central tenet of Root Cause Analysis (RCA) is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals” (AHRQ, 2012). The prevention of errors is the main emphasis of a RCA. The process begins with gathering data in regards to the event, then the data needs to be analyzed, and the final step is to find solutions to the errors that were found so that a reoccurrence of the same error doesn’t occur again. The team should…show more content…
Dr. T was not satisfied with the sedation level and ordered an additional dose of each of the medications only 5 minutes later. It was at this point that the MD noticed that sedation wasn’t initially achieved because of the patients weight an his regular use of oxycodone which was being used to treat his chronic pain in his back. Nurse J. never questioned the orders for medications or the frequency at which they were ordered. It also does not appear that Mr. B’s vitals were ever checked in between medication doses. This all contributed to the incident that occurred. After all the medications were given Mr. B’s vitals were as follows: Blood Pressure (BP) of 110/62, a pulse oximetry reading (Pox) of 92%. At this time Mr. B should have been placed on supplemental oxygen, his respiratory rate (RR) should have been checked and vitals should have been monitored more closely. Also the respiratory therapist could have been called to assess Mr. B’s respiratory states while Nurse J. and Dr. T finished the sedation and reduction process. Per the scenario the hospitals policy requires that patients that receive moderate sedation have continuous BP, ECG, & Pox monitoring done. Nurse J. who was trained in the sedation process and policy, nor the MD followed protocol. The precautionary measures that were required by the hospital could have prevented the outcome of Mr. B. After the sedation and

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