Organizational systems and Quality leadership. C489-Task 2-revised version
Gina Potter
000203903
Western Governor’s University
January 31, 2016, 2016

The goal of this paper is to scrutinize the regrettable sentinel event of Mr. B, a sixty-seven-year-old patient who was admitted to a rural ED with left leg pain that he found unbearable. A root cause analysis will be used to exam the causative factors that led to this unfortunate sentinel event. Then I will identify the errors or hazards in the care of Mr. B. A change theory will then be utilized to establish a useful improvement plan that would hopefully decrease the chances of a repeat of the outcome in the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA) will then be used to project the likelihood that the suggested improvement plan would not fail. In conclusion key roles of the nurses involved in the care in the Mr. B scenario will be discussed.

I have completed the RCA considering: causative factors, errors and hazards that had unfortunately lead to the death of the 67 year old patient that was brought to the ED.

By performing the RCA we start at the beginning with the causative factors, we list staffing levels, who was there and who was not. The participants during the root cause analysis would be the emergency room physician (Dr. T.), the LPN and RN (Nurse J) the respiratory therapist who was in house but not in the ED at the time of this sentinel event, and the unit secretary. As we read through the scenario we discover that conscious sedation was used for Mr. B. Conscious sedation should never take place without a qualified Respiratory Therapist (RT) present. We know that there was an RT in the building at the time of the procedure. Conscious sedation should always include the use of supplemental oxygen with continuous monitoring, as well as careful monitoring of the patients vital