Rca and Fmea

A nurse attending stated “during the morning’s second surgery, he actually dozed off. The nurse took him aside and recommended that he take a break, but he refused and returned to the operation.” The nurse here was in fault in more ways than one. This nurse should never allowed the doctor return back to operate on the patient, he should have been removed from the operating room immediately. The nurse should have

The initial problem with Lewis Blackman's case was that lewis was administered inappropriate medication. First he was given a strong dose of opioid pain medication and on top of that prescribed an adult IV painkiller called Toradol. His medication was being increase even though it was not affecting the patient relieve pain. The nurses fail to diagnose the patient's pain and reevaluate him on his pain status. Followed by that Lewis was having trouble breathing, that is one of the first priorities for a nurse. Yet they assume because he had a history of asthma, him having affected breathing was normal. Therefore, his vital signs, pulse oximeter, were compromised the day after surgery from 90 to 85 which is low. The hospital was not concerned

In the first scenario, I was in the role of the primary nurse. After receiving report, I prioritized patients based upon need and visited Mr. M first. The report mentioned he was having difficulty breathing, and seemed confused throughout the night,

While the seriousness of a patient’s death should be investigated, the hospital failed to act promptly and investigate the supervisor’s or human resource (HR) department’s denial of reasonable accommodations or the previous errors made by the nurse. Therefore, the wrongful termination seems more likely to have been the case in this situation. The defense will show that rather than terminating her employment earlier the hospital waited until something catastrophic happened. The nurse took appropriate action discussing her health condition diagnosed by her physician that precludes her from working in the ER at full capacity with her supervisor. The nurse should have been given alternative assignments as appropriate or disability leave if no other alternative was available and should not have been terminated wrongfully after the incident (Pozgar,

We know that he had sustained an at home fall. We learn that he has a history of pain and a prescription for oxycodone for back pain. We know that his vital signs on admission appear stable; he was not showing any signs of respiratory distress. As we look at the staff that was listed that day we do get the sense the hospital may have been short staffed. Staffing report shows there was one MD, one RN and one LPN managing at least 4 patients including- one patient was a child. Evidence based research has proven that the nurse to patient ratio is directly related to the patient outcomes (Stanton, 2004). It is important that we consider the staffing level that this rural ED as we know short staffing can be blamed for not being able to take the full amount of time needed to do a proper health history. A detailed health history is an imperative part of the care process; it is used by the staff to accurately assess any acute changes that may take place in the patient throughout their stay.

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.

As a result of the failure to adhere to the safety precautions before utilizing the automated external defibrillator the patient was severely burned on his neck and shoulders. “The patient can show a legally sufficient relationship between the breach of duty and the injury; this concept is referred to as proximate causation” (). If standards of care had been meet the injury that the patient now suffers could have been prevented.

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.

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

“One of the largest and most influential electronics companies during the 20th century was the Radio Corporation of America, or RCA. At one time, the breadth of its operations included everything from making vinyl records to building and manufacturing communications satellites.” (Engineering and Technology History Wiki: RCA (Radio Corporation of America)). Today, RCA stands as of the most popular and successful record labels in the music industry, and it serves more purposes now than ever before. Over the years, RCA has taken on responsibilities such as searching for talent, signing talent, developing the artists (sometimes), recording and producing their artists, promoting and marketing their artists, and exploiting their

assess Mr. B’s respiratory states while Nurse J. and Dr. T finished the sedation and reduction

As staff was quickly working to connect the patient to the monitor, obtain IV, EKG and labs the physician was assessing the patient. Shortly after we began our routine process of treatment for this patient he became unresponsive and pulse was lost. Since everyone was already in the room we were able to begin CPR immediately and obtain a pulse within 2 minutes. The gentleman was then rushed to the cath lab where they were able to perform interventions and open up the blocked arteries.

We are living in an era where technology has dominated every major industry. According to our class lecture, (Chamberlain College of Nursing, 2015) every nurse should have the basic computer knowledge and skills so that he or she can access information swiftly and proficiently. In retrospect, to the reading of both text and lesson, it is quite vivid in my mind of the experience that I had with this patient. It was my turn to receive the next admission from the Emergency Room. Initial report given to me was that this 48 year old white male by the name of Mr. M came via Ambulance complaining for Chest Pressure. Vital signs completed as follows: BP 108/62, HR 103, RR27, and oral Temp 97.9 done by EMT reroute. He is a construction worker

The Failure Modes and Effects Analysis (FMEA) and the Root Cause Analysis (RCA) are both used to prevent adverse events from happening. However, they are used at different time periods. Understanding how they are used helps one to understand when to use them.

A root-cause analysis (RCA) is a structured method use for analyzing adverse events. RCA’s are beneficial in identifying problems or issues surrounding the adverse event and pinpointing the root of the problem most likely causing the error, thus avoiding focusing blame on individuals (AHRQ, 2012). Joint commission mandates that hospitals perform RCA’s when adverse events happen. Directing an RCA makes for identification of errors leading up to and surrounding the event.