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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In addition to this matter the medical staff are just as reckless as the doctor in this case because why would any sane person allow a doctor to fall asleep during an operation? They themselves should have noticed the state the doctor was in and took immediate action. This is a medical oath medical professional take and should obey at all times. The medical staff should have alerted the proper authorities in the hospital immediately and the harm on the patient could have been prevented. The medical staff allowed the doctor to fall asleep not once, but seven times. This is beyond shocking, it is a totally outrageous move on all the medical teams behaves.
Drinking age is not a strange phrase in our lives. Every time when we go to club or buy some liquor, we have to show our photo ID to prove that we have already 21 and we are legal to drink wine. I think this is a really good method to control drinking problem. Before I read these two articles which are “The 21-Year-Old Drinking Age: I Voted for it, It Doesn’t Work” by Dr. Morris E. Chafetz and “The Drinking Age of 21 Saves Lives” by Toben F. Nelson and Traci L. Toomey, I only felt that when people grow up they will have self-control to hold their desire for drinking and could decide whether it is appropriate to drink at that moment. I didn’t collect any data or information to support my opinion,
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.
Data can be collected on multiple ways, from the point of medical care and patient satisfaction. The scenario points to pressure ulcers and the use of restraints, in both situations I believe that there was a fundamental lack of knowledge by the staff and disconnect by management.
Not only did insufficient staffing contribute to the causes of this particular event, but human error also played a significant role. When Mr. B arrived at the ED, he was hyperventilating. His leg “appeared shortened.” He had edema in his calf, ecchymosis, limited ROM, and he rated his pain at a ten out of ten. Mr. B also had a history of prostate cancer, impaired glucose tolerance, elevated cholesterol and lipids, and chronic pain. He was admitted to the ED with a plan to relocate his hip. Dr. T ordered diazepam 5.0 mg to be administered through IVP and then just five minutes later ordered 2.0 mg hydromorphone to be administered because it appeared that the diazepam was not having the intended sedating effect. Again, just five minutes later, Dr. T was still not satisfied with the level of sedation and instructed the nurse to
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
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.
a. The LPN was engaged in caring for the emergency transport patient along with the RN and was also in the process of discharging the other two patients. 3. Why did the LPN not notify the RN of the alarm and reading? a. With the information provided, it appears that the LPN was distracted as well as did not follow her scope of practice.
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
Does the compliance with a sedation protocol improve after nurses receive a sedation competency over a three month period? The available data supported the hypothesis that nursing education and competency can lead to consistent best practices and positive outcomes for patients. The answers to this research question can help develop interventions that support best practices for patients who are mechanically ventilated and receiving intravenous sedation.
Mr. B.’s procedure after sedation (was accomplished) was successful and his sedation level continues. Nurse J then applies an automatic blood pressure machine to measure every 5 minutes and a pulse oximeter, however the nurse does not apply any respiratory monitor or heart monitor which are protocol after a sedation procedure. The nurse then rushes out of the room leaving Mr. B. with his son with no medical personnel at the bedside to monitor the patient. No sedation score or neurological assessment of Mr. B. is noted, which should be performed after any procedure including sedation. This data is either missing, not documented or not performed by Nurse J. Mr. B.’s alarm for low saturation is alarming and the LPN enters the room briefly,
The Institute for Safe Medication Practices (ISMP) 2013, reported a case pertaining to the importance of effective communication whereby a 17-year-old patient had an uncomplicated routine tonsillectomy which was performed in a same day ambulatory surgery center. Postoperatively the Certified registered nurse anesthetist administered 150 micrograms of fentanyl but decided to leave it in the IV tubing to infuse slowly for pain control. Upon arrival to the Post Anesthesia Care Unit (PACU), the nurse anesthetist failed to communicate this vital information to the receiving nurse. Because of the ineffective communication, the necessary monitoring and assessment process was not discussed , the need for frequent monitoring which includes waking the patient up periodically to assess the effect of the fentanyl administered was also omitted. Hence appropriate care and monitoring was not given to the patient. About twenty-five minutes later, the patient was found not breathing and with no pulse. The fentanyl that was left in the IV tubing led to respiratory depression which later led to respiratory arrest. All resuscitation efforts were futile, and the patient suffered permanent brain damage due to oxygen deprivation to the
Indeed, as a manager, my first duty would be to investigate this issue and to do right by the patient and investigate the problem by holding a group assessment with my staff. If the staff is not privy of what the nine patients are complaining about, next I must formerly take it upon myself to ensure measures within my hospital so that it will never happen again. No patient should ever be left unattended if they have been given any form of sedation or medication and all healthcare staff should report to a physician if their patients are