Getting To The Root Of The Problem
Organizational Systems and Quality Leadership
RTT1: Task 2 Sections A through D
A. Root Cause Analysis (RCA): A Systems Approach To Error
The RCA seeks to answer four questions:
1. What happened?
a. Patient admitted to triage with probable dislocated / fractured hip status post fall at home.
b. Vital signs: B/P 120/80, HR-88 NSR, T-98.6, RR-32, weight: 175 pounds.
c. Pain rated 10/10.
d. Assessments reveals: Patient appears to be in moderate distress, left leg appears shortened with calf edema, ecchymosis, and limited ROM.
e. Patient’s leg is stabilized and patient is admitted to emergency department.
f. Admitted by Nurse J.
g. RN assesses the patient, updates the ED MD with the assessment findings, and the MD evaluates the patient.
h. After evaluation of patient, MD writes the order for Valium 5 mg.
i. Valium IVP given by RN at 4:05 p.m.
j. At 4:10 (5 minutes later), the Valium appears to have had no effect, and MD instructs RN to administer Dilaudid 2 mg IVP.
k. Dilaudid IVP given at 4:15 p.m.
l. At 4:20 (5 minutes later), MD is not satisfied with patient’s level of sedation and instructs RN to give another 2 mg of Dilaudid IVP and an additional 5 mg of Valium IVP.
m. At 4:25, patient appears to be sedated and MD able to perform reduction of left hip.
n. Procedure concludes at 4:30 p.m. Patient resting without signs of discomfort and distress. No supplemental O2 at this time.
o. ED receives an EMS call for 75-year-old patient in acute respiratory distress en route to ED.
p. RN places patient on automatic blood pressure machine programmed to monitor his B/P every 5 minutes and a pulse oximeter.
q. RN leaves room but allows patient’s son to sit with him as he is being monitored via the blood pressure monitor.
r. 4:35: vitals are: B/P 110/62 and O2 sat is 92%. Remains without supplemental oxygen or ECG and RR monitoring.
s. Pulse ox alarms for O2 sat of 85%.
t. LPN resets the alarm and repeats the B/P reading.
RTT1: Task 2 Sections A through D
A. Root Cause Analysis (RCA): A Systems Approach To Error
The RCA seeks to answer four questions:
1. What happened?
a. Patient admitted to triage with probable dislocated / fractured hip status post fall at home.
b. Vital signs: B/P 120/80, HR-88 NSR, T-98.6, RR-32, weight: 175 pounds.
c. Pain rated 10/10.
d. Assessments reveals: Patient appears to be in moderate distress, left leg appears shortened with calf edema, ecchymosis, and limited ROM.
e. Patient’s leg is stabilized and patient is admitted to emergency department.
f. Admitted by Nurse J.
g. RN assesses the patient, updates the ED MD with the assessment findings, and the MD evaluates the patient.
h. After evaluation of patient, MD writes the order for Valium 5 mg.
i. Valium IVP given by RN at 4:05 p.m.
j. At 4:10 (5 minutes later), the Valium appears to have had no effect, and MD instructs RN to administer Dilaudid 2 mg IVP.
k. Dilaudid IVP given at 4:15 p.m.
l. At 4:20 (5 minutes later), MD is not satisfied with patient’s level of sedation and instructs RN to give another 2 mg of Dilaudid IVP and an additional 5 mg of Valium IVP.
m. At 4:25, patient appears to be sedated and MD able to perform reduction of left hip.
n. Procedure concludes at 4:30 p.m. Patient resting without signs of discomfort and distress. No supplemental O2 at this time.
o. ED receives an EMS call for 75-year-old patient in acute respiratory distress en route to ED.
p. RN places patient on automatic blood pressure machine programmed to monitor his B/P every 5 minutes and a pulse oximeter.
q. RN leaves room but allows patient’s son to sit with him as he is being monitored via the blood pressure monitor.
r. 4:35: vitals are: B/P 110/62 and O2 sat is 92%. Remains without supplemental oxygen or ECG and RR monitoring.
s. Pulse ox alarms for O2 sat of 85%.
t. LPN resets the alarm and repeats the B/P reading.
References: IHI QI 102: The Model for Improvement: Your Engine for Change. (2009, June 1). IHI Open School Professional. Retrieved November 22, 2013, from http://app.ihi.org/lms/coursedetailview.aspx?CourseGUID=41b3d74d-f418-4193-86a4-ac29c9565ff1&CatalogGUID=6cb1c614-884b-43ef-9abd-d90849f183d4 Pasero, C., & McCaffery, M. (n.d.). Conscious Sedation. Conscious Sedation. Retrieved December 9, 2013, from http://prc.coh.org/html/Paserosedation.htm UTMB. (2012, December 19). UTMB-HANDBOOK-OF-OPERATING-PROCEDURES Free PDF. Free PDF Download and Read Online Search Results for utmbhandbookofoperatingprocedureshtml. Retrieved December 18, 2013, from http://www.utmb.edu/policies_and_procedures/IHOP/Clinical/General_Clinical_Procedures_and_Care/IHOP%20-%2009.13.05%20-%20Moderate%20Sedation%20(Conscious%20Sedation).pdf