Root Cause Analysis Paper

Root Cause Analysis (RCA) is a tool to find the root factor in a failure of a system or of a process. In a RCA, we always want to establish the chain of events first. Reviewing the second scenario we have a Mr. B, the patient, Dr. T, RN J and an LPN with no initial. Mr. B comes into the ER with a hip dislocation at 15:30. He is triaged, assessed, history obtained, placed in ER room and the ER physician is updated on patient status and history. Mr. B’s vitals at this time are B/P 120/80, HR 88 and regular, respirations 32.
ER Physician assesses patient and orders Diazepam to be given. Diazepam was given at 16:05.
Dr. T reassessed patient and ordered Hydromorphone which was given at 16:15.
Dr. T reassessed patient, was again unsatisfied with patient sedation and ordered an additional dose of Hydromorphone and Diazepam. This brings the total medication to 10mg of Diazepam and 4 mg of Hydromorphone. Dr. T notes patient weight, 175lbs, and that patient may be opioid tolerant due to home medications.
At 16:25 the patient is once again assessed and is found to be adequately sedated for the procedure. The patient tolerated the procedure, vital sign machines are set for routine and Mr. B remains sedated at 16:30.
At 16:35 Mr. B’s B/P is 110/62, SPO2 is 92%.
Unknown time later Mr. B’s O2 saturation alarm goes off showing 85%. LPN resets alarm and
The plan for conscious sedation was known after the first MD evaluation of Mr. B. This would have been a good time to request the additional staff to come to assist. This would have also allowed adequate staff to be onsite for the respiratory distress case that came in afterwards and the monitoring of the conscious sedation patient. We also had a failure to communicate from the LPN to update the RN or MD of the vital signs findings of an SPO2 sat of 85% and a failure to follow up on the B/P cycle that was repeated at this