Root Cause Analysis Of Case Study Six

The best choice for Mrs. Cook was pain control with early ambulation and self-attempts at coughing. Her pain decreased and became manageable and she began to ambulate more frequently. She did not have any postoperative pulmonary complications and was discharged after 5

Blackman’s complaints, signs, and symptoms were downplayed and eventually he was transferred out of the PACU with no further plan of care, assessment of the issues, or action to alleviate his complaints. 3 days postoperative, with continued scheduled Ketorolac administration, Lewis’ pain was unfathomable. Despite repeated attempts to gain the attention of the healthcare team to Blackman’s impending crisis, his pain was once again downplayed. The nurses again failed to recognize the significance of his increasing abdominal pain and deterioration, chalking it up to gas pain, suggesting only movement and a bath as the acceptable plan of care. Lewis’ symptoms continued to progress and he deteriorated to a state of clinical shock evidenced by abnormally low temperature and increased heart rate and respiratory rate accompanied by extreme paleness, enlarged abdomen, with absent bowel sounds. Inexperience, lack of recognition, and failure to rescue eventually led to the unexpected death of Lewis Blackman (Acquaviva, et al., 2013).

The process is an action plan that tends to illuminate on the strategies to be employed with the purpose of reducing the risk of a similar sentinel event such as that of Mr. B’s scenario. It addresses the responsibility for the oversight, implementation, pilot testing, as well as timelines and strategies for the measurement of actions that are effective (Lewis et al, 2014). All the root cause analysis (RCA) findings conducted above should help in the determination of the appropriate action plan. The appropriate improvement plan in this scenario should encompass the reevaluation of the events that led up to the code blue of Mr. B. The plan should look at the staffing mix, if the licensed personnel are trained appropriately, the patient to nurse ratio in the ER and the types of patients that were in the ER at the time. When

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.

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

A root cause analysis is a systematic approach utilized to identify problems within an event and create a plan for preventing that problem from recurring in the future. To be effective, a timeline of the events are created to help identify those areas that may be the reason for the problem or event, and the relationship between the causal factors and those factors identified to be a reason for the event to have occurred.

This review is to discuss an overview of this case study with a clinical reasoning model and all contributing factors of this event. Then, the critical analysis of three articles relating to the factors with the reasons for the selection and their evaluation will be presented.

The third step of root cause analysis process is identifying possible causal factors (Mind Tools, n.d.). In this step, the team would determine the factors that contributed to the event. In the given scenario, the factors that led to Mr.B’s sentinel event were his tolerance to pain medications and clinical situation (age, weight, and kidney function) were not considered. The emergency department was very busy and understaffed which caused Nurse J to leave the room and unable to monitor the patient closely. Another factor was that the

A friend of mine went to the emergency department because she had severe pain in her right lower abdomen. She received a laparoscope and was notified that she required surgery immediately to get her appendix removed. While the on-call anesthesiologist was caring for a mother in labour leaving her and other patients waiting for care. She waited several hours to get access to an anesthesiologist to receive medical care before her surgical procedure. After her surgery, the surgeon stated her appendix was really severe, and they were lucky enough to perform surgery before it ruptured. If she had waited longer her appendix could’ve ruptured, and it would’ve been very dangerous and life-threatening. Based on this experience I will examine how

According to the probable cause summary created on September 28, 2015, by Officer K. P. Groome, of the Chesapeake Police Department, the following events occurred:

Elliott, M., Page, K., and Worrall-Carter, L. (2012). Reason’s accident causation model: Application to adverse events in acute care. Contemporary Nurse, 43(1), 22-28.

After careful analysis of what had happened and what should have happened takes place, the RCA team should ideally focus on why the adverse events happened. In this step, the goal is pinpoint the direct causes and contributory factors (Ogrinc & Huber, 2013). By doing this, the root cause of an event can be identified. One suggestion made by the Institute of Healthcare Improvement in the root cause analysis process is to ask “Why?” five times (Ogrinc & Huber, 2013).

“Causes.” Mayo Clinic. Mayo Foundation for Medical Education and Research, 2014. Web. 11 Oct. 2014.

Anna is a fifty five year old homeless, unemployed woman who was admitted to the Emergency Room (ER) at Victoria Hospital in London, Ontario for pelvic pain and postmenopausal bleeding. During the nurse’s head-to-toe assessment it was found that the patient also had presenting abdominal distention, prompting her physician to order an X-Ray to determine if a gastrointestinal issue caused this distention. Once this was ruled out, Anna’s physicians continued to search for the underlying cause of her abdominal distention, in addition to her other admitting symptoms. As a result, Anna was admitted to the hospital as an inpatient on the Acute Medicine Unit. The day following admission, Anna went for further testing to hopefully discover the cause of her symptoms. The first test completed was an

I am uncomfortable putting work conflicts on the internet, and even more uncomfortable exposing personal relationship conflicts that should inherently be private. I also do not watch the news, because I do not trust it as a source of information. Thus, for the purposes of this essay, I shall describe the most recent inner conflict of note that I have experienced instead, and analyse it using the “Root Cause Analysis” and “5 Whys” strategies that were discussed in this week’s reading.