RTT1 Task2W
RTT1 Organizational Systems Task 2
Sabrina Bates
Western Governors University
Root Cause Analysis (RCA) is a tool designed to help identify not only what and how an event occurred, but also why it happened. We can see from this scenario that the root cause is the lack of oxygen given to this patient, however it is not the only cause. A string of events lead to this patients demise. The first and most important cause was that hospital policy was overlooked. In the scenario it stated.
Root Cause Analysis (RCA) is a tool designed to help identify not only what and how an event occurred, but also why it happened. We can see from this scenario that the root cause is the lack of oxygen given to this patient, however it is not the only cause. A string of events lead to this patients demise. The first and most important cause was that hospital policy was overlooked. In the scenario it stated
“A moderate sedation/analgesia (“conscious sedation”) policy requires that the patient remains on continuous B/P, ECG, and pulse oximeter throughout the procedure and until the patient meets specific discharge criteria (i.e., fully awake, VSS, no N/V, and able to void).” The trained nurse had the equipment to insure that this policy was followed, however failed to perform her duties as required by this policy. The second event is that the LPN reset the alarm and made no effort to provide an intervention for the alarm. The LPN did not inform the RN of the O2 Saturation level. The LPN Was not trained properly. The third event was that there was not enough staff called in for the level of acuity that these patients had. The administration should have been made aware of the emergency coming in and called in more staff to accommodate the staffing need.
The errors or hazards in care in the scenario were that the RN failed to follow hospital policy to continuous monitor the patient. LPN was not properly trained to handle patients with a higher acuity. LPN failed to
Sabrina Bates
Western Governors University
Root Cause Analysis (RCA) is a tool designed to help identify not only what and how an event occurred, but also why it happened. We can see from this scenario that the root cause is the lack of oxygen given to this patient, however it is not the only cause. A string of events lead to this patients demise. The first and most important cause was that hospital policy was overlooked. In the scenario it stated.
Root Cause Analysis (RCA) is a tool designed to help identify not only what and how an event occurred, but also why it happened. We can see from this scenario that the root cause is the lack of oxygen given to this patient, however it is not the only cause. A string of events lead to this patients demise. The first and most important cause was that hospital policy was overlooked. In the scenario it stated
“A moderate sedation/analgesia (“conscious sedation”) policy requires that the patient remains on continuous B/P, ECG, and pulse oximeter throughout the procedure and until the patient meets specific discharge criteria (i.e., fully awake, VSS, no N/V, and able to void).” The trained nurse had the equipment to insure that this policy was followed, however failed to perform her duties as required by this policy. The second event is that the LPN reset the alarm and made no effort to provide an intervention for the alarm. The LPN did not inform the RN of the O2 Saturation level. The LPN Was not trained properly. The third event was that there was not enough staff called in for the level of acuity that these patients had. The administration should have been made aware of the emergency coming in and called in more staff to accommodate the staffing need.
The errors or hazards in care in the scenario were that the RN failed to follow hospital policy to continuous monitor the patient. LPN was not properly trained to handle patients with a higher acuity. LPN failed to