Root Cause Analysis Essay
Root Cause Analysis (RCA) is a process that is used to identify the causes of an error or accident. In the case of Mr. B death, a RCA is needed to determine what may have contributed to his death. A Root Cause analysis must be complete and reported to Joint Commission in the even where injury or death occurs. Sentinel event is a major adverse even that could have been prevented (Alemi, 2007). The sentinel event was related to respiratory arrest secondary to conscious sedation procedure. The people that would likely be involve in the RCA are the ER physician, the patient nurses including the LPN, ER manager, charge nurse on duty that shift, and the Chief Nursing Officer (CNO) of the hospital. They will meet to discuss the possible cause of Mr. B’s death. The first step in RCA is to data collection. They will assemble patient’s vital signs, his history, and his complaint that the time of arrival and document notes on his since his admission to the hospital. The second step in
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RCA is to discuss the facts that have led to the death of Mr. B. The third step in RCA on Mr. B’s sentinel even is to ask why each of the causative factors that led to Mr. B’s death occurred. The physician not considering patient current renal function level and the patient’s age are a few causative factors that led to his sentinel event. When the members done analyzing the collected information, the even that led to Mr. B’s sentinel event, and causative factors, the team came to the conclusion that the root cause of that patient’s death is medication error. The final last step in RCA is for the RCA team to implement change.
A.) There were many factors that contributed to the sentinel even of Mr.
B, which included poor staffing, the Emergency room was packed with patients and not enough employees to properly monitor and treat them. The blood pressure alarm being silenced by the staff prior to investigating the cause for the buzzing is another mistake by the nurse. Another error by the nurse is that she failed to provide supplemental oxygen to patient prior to imitated diazepam and hydromorphone. The nurse should have known that those medications can cause major respiratory depression and should have taken the precaution necessary to prevent any complication that may have resulted from those two medications. Another error is both the physician and the nurse fell to notice that Mr. B arrived to the hospital with his left leg being shorter than the right leg, red, and swollen. The nurse should have document the condition on of the leg and do a more focus assessment on the extremities to check to
circulation.
RCA is to discuss the facts that have led to the death of Mr. B. The third step in RCA on Mr. B’s sentinel even is to ask why each of the causative factors that led to Mr. B’s death occurred. The physician not considering patient current renal function level and the patient’s age are a few causative factors that led to his sentinel event. When the members done analyzing the collected information, the even that led to Mr. B’s sentinel event, and causative factors, the team came to the conclusion that the root cause of that patient’s death is medication error. The final last step in RCA is for the RCA team to implement change.
A.) There were many factors that contributed to the sentinel even of Mr.
B, which included poor staffing, the Emergency room was packed with patients and not enough employees to properly monitor and treat them. The blood pressure alarm being silenced by the staff prior to investigating the cause for the buzzing is another mistake by the nurse. Another error by the nurse is that she failed to provide supplemental oxygen to patient prior to imitated diazepam and hydromorphone. The nurse should have known that those medications can cause major respiratory depression and should have taken the precaution necessary to prevent any complication that may have resulted from those two medications. Another error is both the physician and the nurse fell to notice that Mr. B arrived to the hospital with his left leg being shorter than the right leg, red, and swollen. The nurse should have document the condition on of the leg and do a more focus assessment on the extremities to check to
circulation.