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Why The Sentinel Event Occurred?

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A root cause analysis is defined as, “a process for identifying the basic or causal factors that underlies variation in performance, including the occurrence or possible occurrence of a sentinel event” (Cherry & Jacob, 2011, p. 442). Involved participants, in the case, the emergency room physician, registered nurse, and licensed practical nurse present during the sentinel event, as well as the emergency room nurse manager, and Chief Nursing Officer, should meet to discuss the events leading up to the patient’s (Mr. B’s) death and establish a root cause analysis. They should explore all hazards and errors in Mr. B’s care. Data should be gathered, facts surrounding the death analyzed, and causative factors should be explored to establish…show more content…
B required as his health deteriorated. The LPN, however, made the error of not notifying the staff of Mr. B’s condition. She again, made the error of simply silencing the patient’s alarms and walking away. Furthermore, according to policy, Mr. B was to be provided supplemental oxygen and continuously monitored, including the use of ECG, throughout the recovery period, for which he did not have. These numerous hazards and errors eventually led to a code situation and ultimately the death of Mr. B. This death, as it turns out, was a result of a simple medication error for which the team must now implement a change to prevent similar errors from occurring again in the future.
B. Improvement Plan
In order to decrease the likelihood that such sentinel event will occur again, a change must be put into place. In this case, the change should involve the process in which conscious sedation is carried out as well as the knowledge of those providing care for those patients. The registered nurse in this case is most likely very good at her job, she probably felt that she had everything under control and has most likely provided conscious sedation many times in the past. As an experienced nurse, however, it is wise to understand that one should never become complacent and it is okay to ask for additional help, especially when a change in patient’s status can occur so quickly. And while this nurse is up to date on her sedation modules
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