Wgu Org Sys2Tems Paper 2

The initial problem with Lewis Blackman's case was that lewis was administered inappropriate medication. First he was given a strong dose of opioid pain medication and on top of that prescribed an adult IV painkiller called Toradol. His medication was being increase even though it was not affecting the patient relieve pain. The nurses fail to diagnose the patient's pain and reevaluate him on his pain status. Followed by that Lewis was having trouble breathing, that is one of the first priorities for a nurse. Yet they assume because he had a history of asthma, him having affected breathing was normal. Therefore, his vital signs, pulse oximeter, were compromised the day after surgery from 90 to 85 which is low. The hospital was not concerned

This case study and the following questions pertain to Mr. Londborg, who came into the hospital with trouble breathing. Through his health history, they found out that he has a history of seizures, hypertension, and chronic obstructive pulmonary disease (COPD). His stay was extended in the hospital due to a respiratory tract infection, decreased kidney function, a blood clot in his leg, and a fall that could have been fatal. The following questions addressed throughout this paper will discuss what happened, why it happened and how it should now be prevented.

The plaintiff in Ard v. East Jefferson General Hospital, stated on 20 May, she had rang the nurses station to inform the nursing staff that her husband was experiencing symptoms of nausea, pain, and shortness of breathe. After ringing the call button for several times her spouse received his medication. Mrs. Ard noticed that her husband continued to have difficulty breathing and ringing from side to side, the patient spouse rang the nursing station for approximately an hour and twenty-five minutes until the defendant (Ms. Florscheim) enter the room and initiated a code blue, which Mr. Ard didn’t recover. The expert witness testified that the defendant failed to provide the standard of care concerning the decease and should have read the physician’s progress notes stating patient is high risk upon assessment and observation. The defendant testified she checked on the patient but no documentation was noted. The defendant expert witness disagrees with breech of duty, which upon cross-examination the expert witness agrees with the breech of duty. The district judge, upon judgment, the defendant failed to provide the standard of care (Pozgar, 2012, p. 215-216) and award the plaintiff for damages from $50,000 to $150,000 (Pozgar, 2012, p. 242).

This paper will analyze the cause of the sentinel event which occurred to Mr. B, a sixty seven year old patient which presented to the emergency room with left leg pain. A root cause analysis will be necessary in this case to investigate the causative factors which led to Mr. B’s sentinel event. The factors in this unfortunate case weather they were errors in his care, or hazards in the system will be identified. The Change theory will be used to develop an improvement plan that will be used to decrease the chances of a reoccurrence of the sentinel event that happened to Mr. B. in the scenario.

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.

Neither staff member identified the downward trending of the patients available vital signs and did not evaluate consciousness of the patient. Failure to assess appropriately and recognize deterioration of the patient resulted in a prolonged period of time in which the patient was not adequately oxygenated. Research has shown that short staffing, with decreased nurse to patient ratio, has been found to be associated with increased mortality (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Joint Commission on Accreditation of Healthcare Organizations, 2005; Needleman, Buerhaus, PKankratz, Leibson, Stevens, & Harris, 2011). This reinforces the need to match staffing with patient census, acuity, and need for nursing care.

Meanwhile, elsewhere in Habersham County, Tom was feeling slightly nervous as he exited the staff lounge and entered the hustle and bustle of County Hospital’s ER to begin his first shift as an RN. The first few hours of his shift passed slowly as Tom mostly checked vital signs and listened to patients complain about various aches, pains, coughs, and sniffles. He realized that the attending physician, Dr. Greene, who was rather “old school” in general about how he interacted with nursing staff, wanted to start him out slowly. Tom knew, though, that the paramedics could bring in a trauma patient at any time.

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

As a result of the failure to adhere to the safety precautions before utilizing the automated external defibrillator the patient was severely burned on his neck and shoulders. “The patient can show a legally sufficient relationship between the breach of duty and the injury; this concept is referred to as proximate causation” (). If standards of care had been meet the injury that the patient now suffers could have been prevented.

Institute for Healthcare Improvement. (2004). Failure mode and effects analysis (FMEA). Cambridge, MA: Institute for Healthcare Improvement.

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

his chronic pain in his back. Nurse J. never questioned the orders for medications or the

4:30 AM. I jump into my car and drive to Vital EMS in Worcester for a fourteen-hour shift as an EMT. Upon entering the ambulance, my partner and I are quickly dispatched to the residence of a 50-year-old male for an unknown medical complaint. As we rush to the scene with lights and sirens, my partner and I know that we must remain calm and immediately begin to allocate tasks. Upon arrival, I rush out of the ambulance and seize the first in bag, an oxygen tank, and the defibrillator. We head into the residence and encounter the patient who complains of chest pain and presented with inadequate oxygen saturation. I immediately realize that

Staffing deficits pose a direct threat of manifesting negative outcomes associated with the delivery of patient care. Anything or anyone that compromises patient care should be eradicated immediately. This author believes that staffing deficits remain a consistent issue due to lack of solutions that actively address the issue. This author believes that inadequate staffing is a major concern due to the degree of harm it can impose on patients. Adverse events associated with

Quality is one of three main sections on health care services. Quality has three dimensions, they are structure, process, and outcome. To identify what are the meaning of these three, it is very important to know what their definitions are as well as examples for each one of them. Structure is the part that focuses of the facilities of a medical clinic or hospital, how well their skills are, the level of the workers’ education as well as training them, and the environment in the organization. For example, there should be workers who have better education and experience in higher level than other staff. If a hospital has an employer with PhD in Healthcare Administration and another worker is a cardiologist, the first one should be the manager according to his background in healthcare and his level of education while the second worker should be the vice manager (Shi and Singh, 2015).