Root Cause Analysis

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

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 plaintiff in Ard v. East Jefferson General Hospital, stated on 20 May, she had rang the nurses station to inform the nursing staff that her husband was experiencing symptoms of nausea, pain, and shortness of breathe. After ringing the call button for several times her spouse received his medication. Mrs. Ard noticed that her husband continued to have difficulty breathing and ringing from side to side, the patient spouse rang the nursing station for approximately an hour and twenty-five minutes until the defendant (Ms. Florscheim) enter the room and initiated a code blue, which Mr. Ard didn’t recover. The expert witness testified that the defendant failed to provide the standard of care concerning the decease and should have read the physician’s progress notes stating patient is high risk upon assessment and observation. The defendant testified she checked on the patient but no documentation was noted. The defendant expert witness disagrees with breech of duty, which upon cross-examination the expert witness agrees with the breech of duty. The district judge, upon judgment, the defendant failed to provide the standard of care (Pozgar, 2012, p. 215-216) and award the plaintiff for damages from $50,000 to $150,000 (Pozgar, 2012, p. 242).

A. A complete root cause analysis (RCA) that incorporates the causative factors, errors, and hazards that led to the patient’s outcome or sentinel event.

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

The history of the Nurse Anesthetist dates back prior to the Civil War and were considered by many as the pioneers of the practice of anesthesia. As the complexity of administering anesthesia increased, physicians deemed the practice of anesthesia to be equivalent to the practice of medicine. As time progressed, some physicians attempted to have the practice of anesthesia banned from the nursing scope of practice. It was not until a case was brought in front of the California Supreme Court where they ultimately established the legal precedent granting nurse anesthesia its legality. Specifying that nurses can administer anesthesia and that they would be operating under their scope of practice as long as it was done under the guidance of a supervising physician (Hamric, Tracy, & O 'Grady, 2014). That law was federally mandated until 2001, when the Centers for Medicare and Medicaid changed the federal supervision rule of Anesthesiologist and Nurse Anesthetists in order for facility to receive reimbursement of care ("Certified Registered Nurse Anesthetists Fact Sheet", 2016). This offered states an “opt-out” rule allowing the unsupervised practice of nurse anesthetists. This change led to conflict in the anesthesia community between physicians and Certified Registered Nurse Anesthetists (CRNA) as the debate of a CRNA’s ability to practice autonomously was now the center of attention. With the costs of healthcare rising and the

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

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

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 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

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

John was a 76 year old gentleman returning to an orthopaedic ward following a total hip replacement under general anaesthetic. The agreed care plan was to regularly monitor John’s vital signs over the next several hours in accordance with local hospital resuscitation trust policy (2012) and the National Institute

According to PC.03.01.03 from The Joint Commission states; the hospital is to provide the patient with preprocedural treatment and services according to their plan of care. The licensed practitioner is to plan or agree with the plan for sedation for each patient.

Some key differences concerning the failure modes and effects analysis (FMEA) and a root cause analysis (RCA) are clarified. Failure mode and effects analysis is conducted prior to any event. FMEA is a preventive action used to help prevent a failure. The FMEA committee consists of about three to four members who all are experts in the designated subject. Through FMEA the committee helps develop action plans to reduce the risk of failure (Quality-One, 2011). RCA is an investigation that occurs after a sentinel event that is unexpected. Through the RCA you are looking to find out why did an event occur or not occur, how the event happened, and how to prevent additional events for occurring (VA National Center for Patient Safety, 2015).

The end all goal of a Root Cause Analysis is to find the root cause of the problem. This process begins with the information that was collected during data gathering and analysis. It focuses on learning what parties were involved, what information they knew and during what time period. The analysis dips further into identifying who is accountable, what they are accountable for and why this method of accountability. The main focus of this evaluation is asking a series of “why” questions to explain how certain events happened (Andersen & Fagerhaug, 2006). Continuing the previous example, the root cause analysis asks direct questions that may be able to explain how the patient ended up slipping and falling. These questions include: why was there water present on the floor, why wasn’t the facilities crew notified of the liquid, why the facilities crew had a delayed response if this message was relayed, and finally, why the nursing home staff took too long to