RTT1 Task 2 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.
A. Root Cause Analysis
“A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals” (AHRQ, 2012). The emphasis of RCA is on error prevention. It is a structured process of gathering data regarding the event, analyzing the information, and finding solutions to the problems to prevent reoccurrences. A
…show more content…
There was additional backup staff present (including a respiratory therapist) that could have been called upon for help, yet they never were. The charge nurse or nurse supervisor could have stepped in at this point to provide additional help. A lack of present nursing staff and support can lead to unfavorable patient outcomes, as is the case with Mr. B. Additionally, the staff on duty could have lacked training regarding protocols or their training could have been out of date.
A1. Errors or Hazards
Not only did insufficient staffing contribute to the causes of this particular event, but human error also played a significant role. When Mr. B arrived at the ED, he was hyperventilating. His leg “appeared shortened.” He had edema in his calf, ecchymosis, limited ROM, and he rated his pain at a ten out of ten. Mr. B also had a history of prostate cancer, impaired glucose tolerance, elevated cholesterol and lipids, and chronic pain. He was admitted to the ED with a plan to relocate his hip. Dr. T ordered diazepam 5.0 mg to be administered through IVP and then just five minutes later ordered 2.0 mg hydromorphone to be administered because it appeared that the diazepam was not having the intended sedating effect. Again, just five minutes later, Dr. T was still not satisfied with the level of sedation and instructed the nurse to
| The business itself does not retain any profits. 100% of profits remain with the owner and is considered personal income.
The Joint Commission is scheduled to visit Nightingale Community Hospital for its triennial accreditation survey within the next 13 months. The purpose of this document is to provide senior leadership with an outline of the hospital’s current compliance status in the Priority Focus Area of Communication. Recommendations for corrective action are included in this document which are designed to bring the organization into full compliance in the areas where deficits have been identified.
Florence Nightingale, considered the founder of modern nursing, first began to establish nursing as a profession during the Crimean War. Since then, nursing theorists have continued to expand on the thought that patients are made up of more than just the symptoms they present with, Abraham Maslow, Carl Jung, Dr. Larry Dossey and Dorothy Johnson, but none more so than Jean Watson. She developed a theory of human caring that contained several core concepts, these concepts lay forth the ground work for how we, as nurses, should care for a patient. These concepts included transpersonal caring relationships (going beyond ego to higher “spiritual” caring
The healthcare systems of Switzerland and the United States are quite similar in some aspects and vastly different in others. In Switzerland, the healthcare is universal and available to all. It is provided by private individual insurance companies and subsidized by the government when needed. Basic health insurance is required to be purchased within 3 months of residency or after birth and is an individual’s choice as to what carrier they choose. Of course, there are exceptions to this mandate but they are very few.("Healthcare in Switzerland," “n.d.”, para. 1) Because of this requirement, 99.5% of the population in Switzerland has
We know that he had sustained an at home fall. We learn that he has a history of pain and a prescription for oxycodone for back pain. We know that his vital signs on admission appear stable; he was not showing any signs of respiratory distress. As we look at the staff that was listed that day we do get the sense the hospital may have been short staffed. Staffing report shows there was one MD, one RN and one LPN managing at least 4 patients including- one patient was a child. Evidence based research has proven that the nurse to patient ratio is directly related to the patient outcomes (Stanton, 2004). It is important that we consider the staffing level that this rural ED as we know short staffing can be blamed for not being able to take the full amount of time needed to do a proper health history. A detailed health history is an imperative part of the care process; it is used by the staff to accurately assess any acute changes that may take place in the patient throughout their stay.
Nestled in Southern Indiana just west of Louisville, Kentucky and south of Indianapolis, Indiana is Dubois County, Indiana. Dubois County is comprised of the towns of Birdseye, Ferdinand, Holland, Huntingburg and Jasper. Of those towns, Jasper is the largest and is the county seat (Kelly School of Business, 2014). Over fifty-two percent of the population consists of adults ranging from 25-64 years of age (Kelly School of Business, 2014). The leading cause of mortality in this county is heart disease, cancer, suicide and injuries (Memorial Hospital and Health Care Center & Dubois County Health Department, 2011).
In September of 2012, beginning in the country of Saudi Arabia, hospitals began seeing increased cases of a respiratory virus never before seen in humans. They named it Middle East Respiratory Syndrome, or MERS. MERS is a viral respiratory illness caused by the coronavirus. It was originally thought to have started there in Saudi Arabia. It was not until later that they were able to trace the origin back to Jordan starting in April of 2012. All outbreaks of MERS have been traced back to originating from the Arabian Peninsula (CDC, 2015a). Unfortunately, it is not known exactly how MERS was contracted in humans, but it is believed to have come from an animal source, probably from camels. Strains of MERS
American Academy of Pediatrics and American Academy of Family Physicians article regarding acute otitis media is a filtered resource. It is an appropriate source for nursing practice because; it establishes clinical guidelines to diagnose and manage AOM. It also establishes guidelines when to treat the signs and symptoms of AOM, watchful waiting, or to treat with an antibiotic. This article is classified as an evidence based guideline because, it reviews multiple research literatures in a systemic manner and provides
I performed a SWOT analysis on the current AEnergy technology infrastructure. A SWOT analysis is a technique and opportunity for a thoughtful overview of where things are good and where things need improvement. SWOT stands for Strengths, Weaknesses, Opportunities, and Threats. I’ve reviewed our system for all four of the SWOT attributes to give the following summary and suggestions.
mitigate these points assessments will be made in how to best mitigate the failure and what would need to be done to
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
I chose to study and analyze J.M.W. Turner’s Slave Ship for this project and found it to be very interesting. Immediately while looking at the piece you get a strong sense of emotion and drama that is being portrayed. There is a lot of depth and warmth in the colors that are used and wide swift brush strokes to create the images. The first image that caught my eye was of waves crashing on the left side of the painting. The white tips of the waves are very noticeable against the softer shades of the ocean. Behind the waves is a ship which is the next part of the painting that drew my attention. The ship seems to be caught in the rough waves of the sea and barely able to keep afloat. There is a glimmer of light from the sun peeking through
It is critical to have an understanding of nursing-sensitive indicators in order to provide safe, quality, compassionate and satisfactory patient care. In this scenario, applying restraints to Mr. J, a demented patient with hip fracture seems appropriate. However, it is standard practice that restraints are to be removed as soon as possible, and the patient in restraints may need assistance to change position every two hours. In Mr. J’s scenario, there should have been a bedside commode, and a urinal for him to use at the bedside so he does not have to walk very far to the restroom. As for the CNA, if she was well trained, she would have been able to recognize the marks on his spine
In this life, there are many forms of art or art “movements” to speak of. How we interpret art is a very subjective thing. What a person sees and feels when looking at art greatly depends on their upbringing, their values, and even their mood at the time of viewing. Could something dark and lacking color be art? What about a comic strip in the newspaper or the billboard down the street? Again, interpretation and taste in art is individual. I elected to explore into the two art movements I like the least to potentially better understand them, and to potentially link them together.
I do not have a written account of the scrub nurses or other Operating Room staff testimony as to what actually happened in this Operating Room. It would be speculation on my part to assume the worst of the physician without having all the details before me.