Organizational Systems and Quality Leadership
Task 2
LaToya Diaz
Western Governors University

Organizational Systems and Quality Leadership Task 2 A. Root Cause Analysis
The Root Cause Analysis is a technique used to determine what happened, why it happened and determine things to do to prevent a reoccurrence. * At 3:30pm a patient arrived to the Emergency Department with a dislocated hip and was experiencing elevated respiration rate of 32 and a significant pain score of 10/10 * At the patients time of arrival there was 1 RN, 1 LPN, 1 Secretary, 1 Emergency room physician, and an in house respiratory therapist on staff at the time of the patient’s arrival and there were two other patients being cared for. * The physician decides to do a reduction of the patients left hip and need to have the patient at an appropriate sedation level * At 4:05pm the nurse administered Diazepam 5mg IV per the physicians order. * At 4:15pm the nurse gave Hydromorphone 2mg IV per the physicians order. * At 4:20pm the patient is still not sedated enough and the nurse gives an additional Diazepam 5mg IV and Hydromorphone 2mg IV. * At 4:25 Proper sedation is achieved and the physician performs a reduction of his left hip. * At 4:30pm the procedure was complete and the nurses are alerted to another patient in route to the ER in acute repertory distress and the nurse places the patient on an automatic blood pressure machine to monitor B/P and pulse oximetry. * At 4:35pm the patient had a B/P reading of 110/62 and O2 stat of 92% * The nurse and LPN receive the ER transport patient and are now discharging the other two patients but the ER has filled with new incoming patients. * The patients O2 saturation alarm is showing a low O2 saturation of 85%, the LPN enters the room and resets the alarm and repeats the B/P reading * The RN