...Western Governors University This paper will analyze the cause of the sentinel event which occurred to Mr. B, a sixty seven year old patient which presented to the emergency room with left leg pain. A root cause analysis will be necessary in this case to investigate the causative factors which led to Mr. B’s sentinel event. The factors in this unfortunate case weather they were errors in his care, or hazards in the system will be identified. The Change theory will be used to develop an improvement plan that will be used to decrease the chances of a reoccurrence of the sentinel event that happened to Mr. B. in the scenario. Root Cause Analysis A root cause analysis, is a system that is used to develop a plan that will identifying the causative factors of an adverse event and formulate a plan to decrease the occurrence or chances of a sentinel event. A team consisting of , a member of the hospital administration, a pharmacist, a respiratory therapist, a charge nurse or nurse manager, a physician, and a member of the family board should be brought together to perform a root cause analysis in this case. These team members would have a meeting to discuss the factors that led to Mr. B’s sentinel event. The first step would be for the team to begin interviewing the staff involved with the case to gather as much data as possible. The data that would be needed include, Mr. B’s vital signs, laboratory results, pain scores, a history of medication that he...
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...Organizational Systems and Quality Leadership Task 2 A. Root Cause Analysis The purpose of this root cause analysis is to carefully examine the causative factors, errors, and hazards that led to the sentinel event of Mr. B’s death. Mr. B was 67 year old male that presented to the ED with his son and neighbor. Mr. B stated that he tripped and fell over his dog. Upon assessment Mr. B’s vital signs were stable with the exception of rapid respirations, his left leg was shortened, red and swollen, and pain was rated 10 on 1-10 scale. The first step to a root cause analysis is to identify what happened. In this scenario, the patient is admitted to an ED room after proper triage. Initially, 5 mg diazepam was ordered by the ED Doctor, and administered by Nurse J at 4:05 pm. After five minutes, no status change is noted and Dr. T ordered 2 mg hydromorphone IVP. This is administered at 4:15 pm. Dr. T then ordered an additional 2 mg hydromorphone IVP, as well as an additional 5 mg diazepam IVP. At 4:25 pm a successful reduction of left hip takes place. At 4:30 the procedure is concluded. The patient remained sedated, showing no signs of distress or discomfort. Mr. B is not currently on supplemental oxygen. Mr. B is placed on an automatic blood pressure machine programmed to monitor the blood pressure every five minutes as well as a pulse oximeter. At 4:35 pm Mr. B blood pressure is 110/62 and O2 saturation is 92%. He has no supplemental oxygen, and his ECG and respirations...
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...Root Cause Analysis Healthcare facilities that are Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredited are required to implement root cause analysis as part of their obligation. The root cause analysis team strives to assess and improve patient outcomes as specific situations occur by forming a team of experts that were involved in the situation. Cases are reviewed and processes are implemented to correct the errors that took place. Four key questions are asked, what happened, why did it happen, what can be changed to prevent it from happening again and how are we going to evaluate the change. This process takes place soon after the event so details are not forgotten. The professionals involved in the root cause analysis would take on roles. The team leader would be a representative from risk management. The nursing supervisor that was working on the day of the event would be the recorder. The team members would include the manager of the emergency department, the RN, LPN, and physician involved with the patient from the emergency department. The advisor would be the chief nursing officer or another member of the executive staff. The first thing is to review the many causative factors that were in place on this particular day. There was inadequate staffing for the emergency department for the number and high acuity of patients that were being treated. There was a hospital protocol for conscious sedation that was not followed. The nurse...
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...A. Root Cause Analysis A root cause analysis (RCA) is a “systematic approach to understanding the causes of an adverse event and identifying system flaws that can be corrected to prevent the error from happening again” (Huber & Ogrinc, 2010). The root cause analysis is used to determine why the problem occurred in the first place and to identify the cause of a problem using a specific set of steps (Mind Tools, n.d.). The RCA team which consists of interprofessionals who are knowledgeable of the issues and processes related to the incident and the people who are involved in the incident should be formed first before the RCA meeting takes place (Huber & Ogrinc, 2010). In the given scenario, the team includes the emergency department (ED) physician (Dr.T), the RN (Nurse J), the LPN (Mr.B’s LPN), the risk manager, the ER nurse manager, the ER nurse educator, and the quality improvement professional. These members would meet and would discuss the causative factors, errors and hazards that caused Mr.B’s sentinel event. The root cause analysis process has five steps. The first step in conducting a RCA is defining the problem (Mind Tools, n.d.). In the given scenario, the problem is the unexpected death of Mr.B. The second step is collecting the data (Mind Tools, n.d.). It is very important to record and report the data as accurately and as completely as possible. Mr. B’s vital signs, pain scores, laboratory values, and history of medication administered during the situation must...
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...Root Cause Analysis: Root cause analysis (RCA) is used in different fields to conduct a systematic search to find the causes of a specific sentinel event (Jacob, 2010). The main goal for conducting a RCA is to prevent similar adverse events from happening in the future (Jacob, 2010). In this paper, I will use the scenario provided in the task to create a complete RCA report as well as improvement plans that will prevent similar incidents from happening again. RCA is best done as soon as an adverse event has happened (Jacob, 2010). The first step in the RCA is to identify what had happened (Jacob, 2010). In the scenario, Mr. B was admitted to the Emergency Room (ER) after a fall. During the treatment, Mr. B was given diazepam intravenous push (IVP) to relax his muscles for examination and hydromorphone IVP to decrease pain during the assessment. The first dose of both medications did not seem to achieve the sedation level that Dr. T had desired. Dr. T also realized that Mr. B had been routinely using oxycodone for chronic back pain. He then decided to administer another dose of the diazepam and hydromorphone. Mr. B was finally sedated enough for the manual manipulation needed during the examination; he tolerated the assessment without discomfort. Right after that, the ED receives an emergency call and Nurse J put Mr. B on an automatic blood pressure and oxygen saturation monitoring every five minutes before leaving the room. A few minutes later, Mr. B’s...
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...often preventable. When such events transpire, it is necessary to fully assess the situation so that these errors can be prevented in the future. Root cause analysis (RCA) is a tool employed by healthcare facilities to analyze adverse events and the systems that lead to them. A. Root Cause Analysis “A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals” (AHRQ, 2012). The emphasis of RCA is on error prevention. It is a structured process of gathering data regarding the event, analyzing the information, and finding solutions to the problems to prevent reoccurrences. A team consisting of the charge nurse, a physician, a respiratory therapist, a pharmacist, hospital administrators, and patients not involved in the case is assembled to work through the process. The team begins by interviewing patients and staff involved to gather as much vital information as possible. Once all necessary information is compiled, the team works together to get to the root(s) of the problem. In the case of Mr. B, there were multiple issues that led to the adverse event as opposed to one root problem. In the process of defining the problem, several causal factors were identified. The error was a result of both facility and human error. Mr. B, a 67-year-old patient, presented to the small, six-room, rural hospital ED due to severe pain in his left hip following a fall. In his quest for care...
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...Root Cause Analysis Root Cause Analysis (RCA) is a process that pinpoints vital or root aspects that determine variation in conduct which includes the result or possible result of sentinel events. (Cherry, B., & Jacob, S. 2014). In the scenario with Mr. B., who was admitted to the Emergency Department (ED) after a fall with left leg and hip pain and was given conscious sedation for a hip reduction that resulted in respiratory arrest and subsequently cardiac arrest. There were several causes of this sentinel event. Hazards include the understaffing of the department and the high census of the ED coupled with a high acuity patient that arrived during Mr. B.’s sedation. More staff on duty, including RN’s and MD’s, could have changed the outcome for Mr. B. Some of the errors that occurred are; staff members ignoring the monitor alarm, the patient was left alone while still in the recovery phase, no supplemental oxygen administered to Mr. B. prior to the sedation, and the ED Physician reviewed Mr. B.’s current medications only after he gave orders for fairly high doses of narcotics and benzodiazepines for an elderly man. Also, reversal medications and CPR was delayed when Mr. B. was found pulseless and apneic. B. Improvement Plan The Emergency Department’s conscious sedation policy would be the first improvement to reduce the likelihood of adverse events like this from happening again. Specifically, changes in administering supplemental oxygen before the beginning of...
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...A) There are several issues in the case of Mr. J that need to be examined. Using nurse sensitive indicators “reflect patient outcomes that are determined to be nursingsensitive because they depend on the quality or quantity of nursing care” (American Sentinel University, 2011). Mr. J. was not receiving acceptable care, because his daughter noticed a red, depressed area over Mr. J’s lower spine, similar to a severe sunburn. This skin condition is the first stage of a developing pressure ulcer. a. Nurses should be aware that a patient with limited mobility is at risk for skin breakdown, and pressure ulcers. Anyone with limited mobility should be assisted to change positions by the care providers on a regular schedule to help circulation and prevent skin breakdown. b. Providers should also consider that the patient is 72, and has fragile skin due to aging skin. This also places the patient at further risk for pressure ulcers. c. The patient is also on restraints, which limits mobility even further. While restraints can help confused patients from falling, they can also cause skin damage. Care providers should continually access the need for using restraints, and remove them as soon as possible. B) Using hospital data on nursing sensitive indicators could advance quality care throughout the hospital. In this case, the hospital should examine the incidence of pressure ulcers, the use of restraints, and dietary requests. a. When examining the pressure...
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...in all facilities. The role they play in the coordination of care is essential for the professionalism of care providers. In the process of care delivery, it is important to understand the medical history of the patient to determine the most appropriate interventions to employ. Care providers should employ interventions that are beside guaranteeing positive health outcomes address the needs and interests of the patient. It is important to include family members in the treatment program since they understand the patient and his needs better. This paper employs Root Cause Analysis approach together with the Failure Mode and Effect Analysis to determine the impact of the events that resulted in the death of a patient Mr. B. A. Root cause analysis The principal purpose of the Root Cause Analysis is to conduct an evaluation of the highest level of the problem to identify the actual cause. In the case scenario, the root cause analysis rules out the possibility of inadequate patient assessment as a contributor to the factors that resulted in the death of the patient (Andersen, Fagerhaug & Beltz, 2009). The patient arrived at the facility complaining of severe pain in the hip region and the left leg. The nurse in charge conducted routine check for vital signs including blood pressure, weight, and heart rate. Most of the patient’s vital signs were normal indicating...
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...organizations accredited by the Joint Commission are required to conduct a root cause analysis (RCA) in response to any sentinel event such as the one described below. Once the cause is identified and a plan of action established, it is useful to conduct a failure mode and effects analysis (FMEA) to reduce the likelihood that a process would fail. As a member of the healthcare team in the hospital described in this scenario, you have been selected as a member of the team investigating the incident. Scenario: It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient, arrives at the six-room emergency department (ED) of a sixty-bed rural hospital. He has been brought to the hospital by his son and neighbor. At this time, Mr. B is moaning and complaining of severe pain to his (L) leg and hip area. He states he lost his balance and fell after tripping over his dog. Mr. B was admitted to the triage room where his vital signs were B/P 120/80, HR-88 (regular), T-98.6, R-32, and his weight was recorded at 175 pounds. Mr. B. states that he has no known allergies and no previous falls. He states, “My hip area and leg hurt really bad. I have never had anything like this before.” Patient rates pain at ten out of ten on the numerical verbal pain scale. He appears to be in moderate distress. His (L) leg appears shortened with swelling (edema in the calf), ecchymosis, and limited range of motion (ROM). Mr. B’s leg is stabilized and then he is further evaluated and discharged from...
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...organizations accredited by the Joint Commission are required to conduct a root cause analysis (RCA) in response to any sentinel event such as the one described below. Once the cause is identified and a plan of action established, it is useful to conduct a failure mode and effects analysis (FMEA) to reduce the likelihood that a process would fail. As a member of the healthcare team in the hospital described in this scenario, you have been selected as a member of the team investigating the incident. Scenario: It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient, arrives at the six-room emergency department (ED) of a sixty-bed rural hospital. He has been brought to the hospital by his son and neighbor. At this time, Mr. B is moaning and complaining of severe pain to his (L) leg and hip area. He states he lost his balance and fell after tripping over his dog. Mr. B was admitted to the triage room where his vital signs were B/P 120/80, HR-88 (regular), T-98.6, R-32, and his weight was recorded at 175 pounds. Mr. B. states that he has no known allergies and no previous falls. He states, “My hip area and leg hurt really bad. I have never had anything like this before.” Patient rates pain at ten out of ten on the numerical verbal pain scale. He appears to be in moderate distress. His (L) leg appears shortened with swelling (edema in the calf), ecchymosis, and limited range of motion (ROM). Mr. B’s leg is stabilized and then he is further evaluated and discharged from...
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...Christian Duty in the Natural World It is the responsibility of Christians across the United States, as well as globally, to protect, preserve and repair the natural environment of the planet. When individuals pollute or otherwise harm the planet, they are, in effect, disrespecting God. While this may seem farfetched, it is rational when one recognizes that humans first assumed the responsibility of tending the global environment when they entered into the very first covenant with God during the times of the Israelites. Additionally, while having broad focus on what to fix may be preferable to some, there are better methods for beginning the conservation work. In the very first book of the Holy Bible we see God demanding of us to be stewards of the environment. In the Bible we see, “The Lord God took the man and put him in the Garden of Eden to work it and take care of it.” (ESV Study Bible: English Standard Version, Gen. 2:15) In this passage it is clearly apparent that God assigned the responsibility of stewardship of the planet to man. By taking a more allegorical approach to this particular piece of the Bible, a reader can see that the Garden of Eden is actually the planet Earth itself, pre-sin, and God’s placement of Man and directions to him as the charge put forth on maintaining the planet. Yet another example is found in Leviticus 25:23, “The land shall not be sold in perpetuity, for the land is mine. For you are strangers and sojourners with me.” In this verse...
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...in all facilities. The role they play in the coordination of care is essential for the professionalism of care providers. In the process of care delivery, it is important to understand the medical history of the patient to determine the most appropriate interventions to employ. Care providers should employ interventions that are besides guaranteeing positive health outcomes address the needs and interests of the patient. It is important to include family members in the treatment program since they understand the patient and his needs better. This paper employs Root Cause Analysis approach together with the Failure Mode and Effect Analysis to determine the impact of the events that resulted in the death of a patient Mr. B. A. Root cause analysis The principal purpose of the Root Cause Analysis is to conduct an evaluation of the highest level of the problem to identify the actual cause. In the case scenario, the root cause analysis rules out the possibility of inadequate patient assessment as a contributor to the factors that resulted in the death of the patient (Andersen, Fagerhaug & Beltz, 2009). The patient arrived at the facility complaining of severe pain in the hip region and the left leg. The nurse in charge conducted a routine check for vital signs including blood pressure, weight, and heart rate. Most of the patient's vital signs were normal indicating that he did not have a life-threatening...
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...Riccobono Western Governors University Organizational Systems and Quality Leadership Task 2 A. Root Cause Analysis A root cause analysis (RCA) looks at an event and considers what happened, why it happened what will be done to prevent it from happening again and how will we know that the changes made will improve the safety of the system. It takes into consideration causative factors, errors and hazards that led to a sentinel event. In this case it was a patient’s death. RCA should not look to place blame on people, but rather processes that need to be improved. The first step in a RCA is to identify what happened. In the scenario, presented in this task, the patient was over sedated and subsequently died. Step two is to identify why this happened. There were preventable causative factors, or errors, that led to this sentinel event. The hospital’s conscious sedation policy requires that the patient remains on continuous BP, ECG, and pulse oximeter throughout the procedure and there was no mention that this was performed at all throughout the procedure. It was not until after the procedure that Mr. B was placed on continuous BP and pulse oximeter, and at that time, the patient was left in the room, with only a family member while Nurse J attended to another patient. When the alarm is heard that the patient has low O2 sats, the LPN, enters the room and resets the alarm and repeats the B/P reading. His oxygen level was not rechecked, nor was he placed on supplemental oxygen, nor...
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...Abstract Hydroponics is a method where the roots or the half of the shoot system of the plants are subjected to water which itself will become the growing medium of the mentioned plant. Moreover, this kind of technique is used mostly by soil less society wherein scarcity in soil has been a distress also to the results of modernization. In relation to that is Aeration, a process of applying Oxygen amounts in a Hydroponics system. The researchers plan to investigate the effect of Aeration to the growth of the subjected plants. The students are also aimed to promote the concept of Hydroponics with an alternative source of Oxygen. In the study, Plants such as Kinchay and Mung beans were planted in two containers A and B and tested for five days. An ordinary Air pump was used in Container A as a supply of Oxygen which will be induced to water. Records were tabulated and posted in different tables. Results include that Plant A and Mung bean C have more changes consisting of root elongation and branching activity. On the findings, Plant A has 0.6 mm primary root improvement compared to the 0.3 mm improvement of Plant B. Based on the observations, Plant C has more maturity than in Plant D. Such records show that the Oxygen induced water...
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