RTT TASK 2
Running head: RTT1 TASK 2
RTT1 Task 2
Angela Kroemer
Western Governors University
Organizational Systems and Quality Leadership
RTT1 Task 2
A. Complete a root cause analysis that takes into consideration causative factors that led to the sentinel event. (This patient’s outcome)
The terms failure analysis, incident investigation, and root cause analysis are used by organizations when referring to their problem solving approach. Regardless of what it’s called there are three basic questions to every investigation:
1. What’s the problem(s)?
2. Why did it happen? (the causes)
3. What specifically should be done to prevent it? (Galley, n.d., ∂ 1)
In the case of Mr. J, these were multiple issues that led to and contributed to his unexpected demise after what is usually considered a routinely performed procedure in an emergency department setting. The JCHAO (Joint Commission on Accreditation of Healthcare) defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury”, (Frain, Murphy, Dash, & Kassai, ∂ 1) and in the case of Mr. B, his death would be considered a sentinel event which would warrant a review by a team of interdisciplinary members of the hospital. In this particular case members of the team would include one or more ED physicians, the RN in the scenario and the LPN, a respiratory therapist, a nursing supervisor, a hospital administrator, the ED nurse manager, a hospital pharmacist, and a risk manager. More staff nurses from the ER could also be involved. A credible and successful root cause analysis will identify all of the elements that contributed to the event, an action plan will be developed to prevent the event from reoccurring and ensure that those actions are completed. Action plans should be based on best practices and appropriate standards. (Frain et al., ∂ 10)
The scenario presented starts out as what appears to be an average afternoon shift in a small 6 bed emergency
RTT1 Task 2
Angela Kroemer
Western Governors University
Organizational Systems and Quality Leadership
RTT1 Task 2
A. Complete a root cause analysis that takes into consideration causative factors that led to the sentinel event. (This patient’s outcome)
The terms failure analysis, incident investigation, and root cause analysis are used by organizations when referring to their problem solving approach. Regardless of what it’s called there are three basic questions to every investigation:
1. What’s the problem(s)?
2. Why did it happen? (the causes)
3. What specifically should be done to prevent it? (Galley, n.d., ∂ 1)
In the case of Mr. J, these were multiple issues that led to and contributed to his unexpected demise after what is usually considered a routinely performed procedure in an emergency department setting. The JCHAO (Joint Commission on Accreditation of Healthcare) defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury”, (Frain, Murphy, Dash, & Kassai, ∂ 1) and in the case of Mr. B, his death would be considered a sentinel event which would warrant a review by a team of interdisciplinary members of the hospital. In this particular case members of the team would include one or more ED physicians, the RN in the scenario and the LPN, a respiratory therapist, a nursing supervisor, a hospital administrator, the ED nurse manager, a hospital pharmacist, and a risk manager. More staff nurses from the ER could also be involved. A credible and successful root cause analysis will identify all of the elements that contributed to the event, an action plan will be developed to prevent the event from reoccurring and ensure that those actions are completed. Action plans should be based on best practices and appropriate standards. (Frain et al., ∂ 10)
The scenario presented starts out as what appears to be an average afternoon shift in a small 6 bed emergency