Root Cause Analysis Essay

1238 Words Aug 14th, 2014 5 Pages
Root Cause Analysis Healthcare facilities that are Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredited are required to implement root cause analysis as part of their obligation. The root cause analysis team strives to assess and improve patient outcomes as specific situations occur by forming a team of experts that were involved in the situation. Cases are reviewed and processes are implemented to correct the errors that took place. Four key questions are asked, what happened, why did it happen, what can be changed to prevent it from happening again and how are we going to evaluate the change. This process takes place soon after the event so details are not forgotten. The professionals involved in the …show more content…
The patient was resuscitated and intubated and sent to the ICU. Seven days later the patient was declared brain dead and expired after the removal of life support. To prevent this scenario from happening again many things can occur. Benchmarking to assess for adequate staffing needs during high volume times in the emergency department. Implement a process to fill staffing needs in these times of high volume. Also educating the staff on conscious sedation protocol and medication administration for patient populations related to age, comorbidities and current medication regimen. Monitoring the use of policies and procedures to make sure that they are being followed and remain safe for the patient.
Errors in the Care In the care of Mr. B the following errors occurred:
The patient was not placed on the ECG monitor
He was not placed on any supplemental oxygen
There was no staff in the room monitoring the patient while still under conscious sedation
The LPN resets the alarm on the oxygen monitor and leaves the room without reporting it to anyone.
Not having adequate staffing for the high acuity of patients in the Emergency Department The nurse should have contacted the nursing supervisor to ask for a person certified to do conscious sedation to come and monitor the patient. This alone would have prevented many of the other errors that occurred. The patient would have been placed on the monitor and oxygen would have been delivered prior to
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