Wgu Organizational Trends Essay

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Organizational Leadership WGU 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. Sentinel event refers to the occurrence of serious physical illness or death or psychological injury or even those incidences whose recurrence involves risks with adverse and serious outcomes. It may result into deaths that are not anticipated or permanent loss of a major function that is not associated with patient’s natural cause of illness or condition (Lewis et al, 2014). The causative factors of Mr. B’s demise, according to the scenario described are that Mr. B was not put on oxygen or an EKG monitor…show more content…
A breakdown of the causative factors that led to Mr. B’s demise is as follows: Failure of O2 and being placed on the EKG monitor Lack of continual monitoring post sedation by staff member Lack of enough trained staff in conscious sedation available at the time of the procedure Resetting of alarms without action Not enough staff present in the ER during high patient volume and acuity B. Discussion on the process improvement plan that is likely to decrease or eliminate the reoccurrence of the outcome or scenario. The process is an action plan that tends to illuminate on the strategies to be employed with the purpose of reducing the risk of a similar sentinel event such as that of Mr. B’s scenario. It addresses the responsibility for the oversight, implementation, pilot testing, as well as timelines and strategies for the measurement of actions that are effective (Lewis et al, 2014). All the root cause analysis (RCA) findings conducted above should help in the determination of the appropriate action plan. The appropriate improvement plan in this scenario should encompass the reevaluation of the events that led up to the code blue of Mr. B. The plan should look at the staffing mix, if the licensed personnel are trained appropriately, the patient to nurse ratio in the ER and the types of patients that were in the ER at the time. When

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