One outlier in this scenario that could have been addressed is the bruising and swelling of Mr. B.’s calf. In the event it was determined before-hand it was indeed a deep vein thrombus, it could have become dislodged during the hip manipulation procedure, causing a large emboli. The emboli, or blood clot, could have moved and blocked blood flow to the heart, which could cause a medical emergency in itself. If the family request an autopsy this report can provide clarification, it a blood clot or emboli indeed existed and if it was a determining factor in the terrible outcome of this scenario. Not knowing this information it will not be used in regard to root cause analysis in this paper, due to this might be a complete hypothesis. Inadequate staffing is the highest order root cause for this unfortunate event. The four identified root cause analysis in this paper are in order inadequate staffing, sedation protocol, post sedation monitoring, and LPN monitoring post
One outlier in this scenario that could have been addressed is the bruising and swelling of Mr. B.’s calf. In the event it was determined before-hand it was indeed a deep vein thrombus, it could have become dislodged during the hip manipulation procedure, causing a large emboli. The emboli, or blood clot, could have moved and blocked blood flow to the heart, which could cause a medical emergency in itself. If the family request an autopsy this report can provide clarification, it a blood clot or emboli indeed existed and if it was a determining factor in the terrible outcome of this scenario. Not knowing this information it will not be used in regard to root cause analysis in this paper, due to this might be a complete hypothesis. Inadequate staffing is the highest order root cause for this unfortunate event. The four identified root cause analysis in this paper are in order inadequate staffing, sedation protocol, post sedation monitoring, and LPN monitoring post