RTT1 Task 2
RTT1 Organizational Systems
Organizational Systems & Quality Leadership
Western Governors University
A. Root Cause Analysis
A complete root cause analysis (RCA) for Mr. B. is described below.
Date of event: Thursday, __________ Time of event: 4:43
Detailed description of event including timeline: Thursday 3:30 pm Mr. B a 67 year old patient was admitted to the ER after a tripping and falling over his dog at his home by nurse J. He was complaining of 10/10 pain to his left leg and hip region but appears to be in only moderate distress. Mr. B’s vital signs were stable at time of admit with a blood pressure of 120/80, heart rate of 88 and increased respirations of 32. Left leg is shortened, swollen in the calf, bruising present and limited range of motion to left leg. Dr. T looked over data and ordered Mr. B to have medications for pain control and sedation in order to perform a manual manipulation in realigning Mr. B’s dislocated hip. 4:05 nurse J administered IV Diazepam per Dr. T’s orders. With no affect Dr. T. orders Nurse J to give 2mg IVP Dilaudid at 4:15. 4:20 Dr. T. orders nurse J to give 2mg IVP Dilaudid for muscular skeletal relaxation. Dr. T. notes that per patient’s weight and regular usage of Oxycodone, it was making it more difficult to achieve the level of sedation required for manual manipulation. 4:25 Mr. B appears sedated and comfortable and procedure of manual manipulating the dislocated hip back in place goes successfully and concludes at 4:30 with the patient resting and no signs of distress. Nurse J. places Mr. B on an automatic blood pressure machine and oxygen saturation to go off every five minutes and leaves to take care of another patient, with Mr. B’s son at the bedside. 4:35 Mr. B’s blood pressure is 110/62 and saturation of 92% on room air. The LPN hears a “low saturation O2” alarm and notes Mr. B’s saturation is 85% room air and repeats the blood pressure setting and resets the alarm. 4:43
Organizational Systems & Quality Leadership
Western Governors University
A. Root Cause Analysis
A complete root cause analysis (RCA) for Mr. B. is described below.
Date of event: Thursday, __________ Time of event: 4:43
Detailed description of event including timeline: Thursday 3:30 pm Mr. B a 67 year old patient was admitted to the ER after a tripping and falling over his dog at his home by nurse J. He was complaining of 10/10 pain to his left leg and hip region but appears to be in only moderate distress. Mr. B’s vital signs were stable at time of admit with a blood pressure of 120/80, heart rate of 88 and increased respirations of 32. Left leg is shortened, swollen in the calf, bruising present and limited range of motion to left leg. Dr. T looked over data and ordered Mr. B to have medications for pain control and sedation in order to perform a manual manipulation in realigning Mr. B’s dislocated hip. 4:05 nurse J administered IV Diazepam per Dr. T’s orders. With no affect Dr. T. orders Nurse J to give 2mg IVP Dilaudid at 4:15. 4:20 Dr. T. orders nurse J to give 2mg IVP Dilaudid for muscular skeletal relaxation. Dr. T. notes that per patient’s weight and regular usage of Oxycodone, it was making it more difficult to achieve the level of sedation required for manual manipulation. 4:25 Mr. B appears sedated and comfortable and procedure of manual manipulating the dislocated hip back in place goes successfully and concludes at 4:30 with the patient resting and no signs of distress. Nurse J. places Mr. B on an automatic blood pressure machine and oxygen saturation to go off every five minutes and leaves to take care of another patient, with Mr. B’s son at the bedside. 4:35 Mr. B’s blood pressure is 110/62 and saturation of 92% on room air. The LPN hears a “low saturation O2” alarm and notes Mr. B’s saturation is 85% room air and repeats the blood pressure setting and resets the alarm. 4:43