Essay on Sat Task 2

3072 Words Feb 25th, 2016 13 Pages
A. Root Cause Analysis A root cause analysis (RCA) is a “systematic approach to understanding the causes of an adverse event and identifying system flaws that can be corrected to prevent the error from happening again” (Huber & Ogrinc, 2010). The root cause analysis is used to determine why the problem occurred in the first place and to identify the cause of a problem using a specific set of steps (Mind Tools, n.d.). The RCA team which consists of interprofessionals who are knowledgeable of the issues and processes related to the incident and the people who are involved in the incident should be formed first before the RCA meeting takes place (Huber & Ogrinc, 2010). In the given scenario, the team includes the emergency department (ED) …show more content…
by Nurse J. After five minutes, the diazepam had no effect so Dr.T ordered two milligrams of hydromorphone IVP given at 4:15 in the afternoon. The patient received another two milligrams of hydromorphone IVP and five milligrams diazepam IVP at 4:20 p.m. because Dr.T was not satisfied with the patient’s level of sedation. When the patient appeared to be sedated at 4:25 in the afternoon, the reduction of his left hip took place. At 4:35 p.m., Mr. B’s BP is 110/62 and his oxygen saturation is 92%. The “conscious sedation” policy was not followed. He did not have supplemental oxygen and his ECG and RR were not monitored. Then, Mr.B’s oxygen saturation dropped to 85%. The LPN adjusted the alarm and repeated the BP reading. Nurse J and the LPN were very busy taking care of the other patients during this time. At 4:43 p.m., Mr. B was not breathing, had no pulse, BP is 58/30 and oxygen saturation is 79%. The stat code was called. 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

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