Essay on Root Cause Analysis of a Sentinel Event

Environmental Factors: The hospital is a very busy place. The background noise can distract the attention of the physicians while they ponder over the right prescription of a drug. The high demand of a medical profession can be stressful and lead to fatigue. These possible occupational hazards can contribute to medical errors.

Alarm fatigue is a growing national problem within the health care industry that links medical technology as a serious hazard that poses a significant threat to patient safety within hospitals across the country. Alarm fatigue occurs when nurses encounter an overwhelming amount of alarms thus becoming desensitized to the firing alarms. Alarm desensitization is a multifaceted issue that is related to the number of alarming medical devices, a high false alarm rate, and the lack of alarm standardization in hospitals today (Cvach, 2012). Desensitization can lead to delayed response times, alarms silenced or turned off, or alarms adjusted to unsafe limits, which can create a dangerous situation for the patient. Alarm fatigue

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.

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

A root cause analysis (RCA) looks at an event and considers what happened, why it happened what will be done to prevent it from happening again and how will we know that the changes made will improve the safety of the system. It takes into consideration causative factors, errors and hazards that led to a sentinel event. In this case it was a patient’s death. RCA should not look to place blame on people, but rather processes that need to be improved.

Additionally, the Moderate Sedation Monthly Audit of the Endoscopy Department shows some compliancy issues regarding pre-procedure events. Mallampati classification, ASA, Sedation plan documentation, and completion of reassessment are consistently below 90% for all

A policy for conscious sedation was in place and not followed by staff. As all staff had been trained in the procedure, completed the appropriate modules, and

Never events are serious medical errors that are often preventable. When such events transpire, it is necessary to fully assess the situation so that these errors can be prevented in the future. Root cause analysis (RCA) is a tool employed by healthcare facilities to analyze adverse events and the systems that lead to them.

Alarm fatigue in health care has grown to be an ever-growing concern in the health care arena, especially when looking at patient safety concerns. There must be an understanding of the problem before we can develop policies and effective strategies to counter this problem. The concept of alarm fatigue in health care will be evaluated utilizing the method developed by Walker and Avant (2010) that identifies and gives the significance of the attributes, antecedents, and end-consequences of alarm fatigue in health care. This will be developed based

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

sedation have continuous BP, ECG, & Pox monitoring done. Nurse J. who was trained in the

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.

Incident reporting mechanism is an essential component in nursing occupation that facilitates the identification and monitoring of adverse events or incidents that occur during health care service. It is a defined procedures and protocols that should be place and disseminate throughout the organization. The reporting system is used to report occurrence such as falls, safety issues for patients, medication errors, treatment and procedural problems, and malfunctioning equipment. The benefit of incident reporting mechanism is to protect patient from injury or harm. In order to maximize patient safety, adverse events, mistakes and errors, and near misses incidents should be report in a timely and accurate manner. Furthermore, it is also used to make the nurse aware of inadequacies of her own part which make her reflect upon the situation and how this could be learned from, so as to prevent making same mistake again.