Why The Sentinel Event Occurred?

Medical error is the third leading cause of death in the US, right behind heart disease and cancer. More than 200,000 people die annually as a result of diagnostic mistakes and negligence by healthcare professionals (Washingtonpost, 2016). In the healthcare industry, even the smallest mistakes and oversight could lead to severe consequences for both the patient and professionals. A healthcare professional would be held liable for any discrepancies that causes harm. The following case will analyze the ethical issue and negligence that lead to the death of an elderly woman.

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.

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.

The goal of this paper is to scrutinize the regrettable sentinel event of Mr. B, a sixty-seven-year-old patient who was admitted to a rural ED with left leg pain that he found unbearable. A root cause analysis will be used to exam the causative factors that led to this unfortunate sentinel event. Then I will identify the errors or hazards in the care of Mr. B. A change theory will then be utilized to establish a useful improvement plan that would hopefully decrease the chances of a repeat of the outcome in the Mr. B scenario.  A Failure Modes and Effects Analysis (FMEA) will then be

A root cause analysis (RCA) looks at an event and considers what happened, why it happened what will be done to prevent it from happening again and how will we know that the changes made will improve the safety of the system. It takes into consideration causative factors, errors and hazards that led to a sentinel event. In this case it was a patient’s death. RCA should not look to place blame on people, but rather processes that need to be improved.

A policy for conscious sedation was in place and not followed by staff. As all staff had been trained in the procedure, completed the appropriate modules, and

November, 1999 brought about a release of a report prepared by the prestigious National Academy of Science’s Institute of Medicine (IOM) making medical mistakes and their magnitude of the risks to patients receiving hospital care to common public knowledge. The IOM concluded that between 44,000-98,000 deaths occur annually because of medical errors. Among a general agreement was that system deficiencies were the most important factor in the problem and not incompetent or negligent physicians and other caregivers (Sultz & Young, 2010). An excellent example of a system deficiency that leads to a crisis and sentinel event was the highly publicized overdose of Heparin to Dennis Quaid’s newborn twins in 2007.

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.

The Association of Anaesthetists of Great Britain and Ireland (AAGBI, 2010) accentuated that when looking after a patient during anaesthetic care, the anaesthetic nurse must be competent in any circumstances for the safety of patient. On the case of Mrs D, there was an obvious need to communicate, so the anaesthetic nurse needs to be trained and encouraged appropriately (Mellanby, Podmore and McNarry, 2014). It is evident that the anaesthetic nurse needs to be confident enough when looking after patients to voice any concerns to the assembled team, regardless of how senior or intimidating they may appear (NMC, 2015). The anaesthetic nurse said that she communicated with the anaesthetists during this critical incident. Yet, the anaesthetists

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.

A root cause analysis (RCA) is a method by which we can examine a serious adverse event and identify the cause, or causes, that led up to the event. Although personnel are involved in these events, the primary purpose of the RCA is to identify the cause, not to assign blame (Agency for Healthcare Research and Quality, 2014). It is through identifying a cause, or causes, of an adverse event that we can improve on patient care processes and thereby patient safety. The RCA is designed as a specific protocol that starts with data collection looking at the sequence of events that led to the

A root cause analysis (RCA) is an essential tool that can be used to examine and understand the ways in which systems fail as well as discuss those specific failures that led to a specific adverse event and potentially implement steps or behaviors to prevent that event from happening in the future (Ogrinc & Huber, 2013). In the case study presented, a number of system failures may have contributed to the patient outcome. As such, an RCA of the case study would help determine those specific

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

Even if no one found out about this mistake, eventually it could happen again if you don’t take the necessary steps to correct your mistake, and this time it could be deadly for your patient.