C489 Task 2 - Running Head C489 TASK 2 1 Organizational Systems and Quality Leadership Task 2 WGU TASK 2 2 A Root Cause Analysis A root cause

C489 Task 2 - Running Head C489 TASK 2 1 Organizational...

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Running Head: C489 TASK 2Organizational Systems and Quality LeadershipTask 2WGU1
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TASK 2 A.Root Cause AnalysisA root cause analysis (RCA) is an approach used in healthcare to answer what happened, why did it happen and how to prevent it from happening again in response to an error that has occurred [Ins10]. In the provided scenario Mr. B ultimately died as a result of receiving sedation in the emergency and subsequently going into cardiopulmonary arrest. Several factors contributed to this outcome. Factors that had a causative effect on this outcome include, too much sedation over a short period of time. The patient received a total of 4 mg of hydromorphone and 10 mg diazepamin a 15-minute span. The onset time of hydromorphone is 10-15 minutes with a peak time of 15-30 minutes and diazepam has an onset of 1-5 minutes with a peak time of 15-30 minutes[UnkND]. The patient was never placed on ECG monitor as per policy to detect any decreased heart rate or abnormal heart rhymes that may occur with conscious sedation. No supplemental oxygen was provided to the patient during or immediately after sedation despite the increased risk of hypoxia with sedation. There was no nurse monitoring the patient after sedation. The patient simply remained on continuous B/P and pulse oximeter. There was no monitoring of respirations or ECG. Policy states patient is to remain on continuous B/P, ECG, and pulse oximeter throughout procedure and until patient meets specific discharge criteria (fullyawake, VSS, no N/V and able to void). And finally when the LPN responded to the low O2 saturation alarm and finding the patients oxygen level at 85% this abnormal finding was not reported to RN or doctor so appropriate action could have been taken. Errors that contributed to the outcome include, not enough staff to appropriately care for amount and type of patients. There was only1 RN and 1 LPN on duty with 3 patients in the emergency room at the time Mr. B was sedated and they were getting a 4th emergency patient 2
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TASK 2 shortly after Mr. B was sedated. Not calling for back up help. Knowing that administering IV sedation would require closer monitoring of the patient, and that there was a 4themergency patient on the way to the emergency department, the RN should have called for the back up staff.And finally, Mr. B’s use of narcotics for back pain. The use of narcotics could have made the effects of the sedation less effective. B.Improvement PlanThe first step in developing an improvement plan is to form a team. For this scenario team members could consist of someone from risk management or quality improvement department, medical director of ER, director of nursing, ER charge nurse, and a respiratory therapist. The next step is to determine exactly what happened. This can be done through interviewing those directly involved in the event, reviewing the incident report, and doing a through chart review. After determining what actually happened the team then would review what should have happened. This comparison helps the team identify causes of the sentinel
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