Essay on Root Cause Analysis of a Sentinel Event

2507 WordsSep 1, 201411 Pages
ROOT CAUSE ANALYSIS OF A SENTINEL EVENT Diane Swintek Western Governors University Root Cause Analysis of a Sentinel Event 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…show more content…
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. Another causative factor was the drug selection. The same moderate sedation-training module that practitioners complete contains a section on appropriate drug selection. Moderate sedation is designed to alter the level of consciousness of the patient while enabling the patient to maintain independently a patent airway (Pinto, Bhimani, Milne, and Nicholson, 2013). The drugs used during this procedure were a potent benzodiazepine and opioid analgesic. If using Valium for sedation/relaxation a narcotic dose is reduced by one third or omitted entirely (Medscape, 2014). The addition of the full dose of an
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