C489TASK2REVISED3-11-17.pdf - Jessica Samples...

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Jessica Samples Organizational Systems and Quality Leadership Task 2
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Root Cause Analysis Incidence Mr. B, a 67-year-old patient was brought to the six-room emergency department on Thursday at 3.30 p.m. after falling following tripping over his dog. Mr. B complains that his hip hurt badly and rates pain ten out of ten. After evaluation of Mr. B, the Emergency Department Physician writes the order for Nurse J to administer diazepam 5mg IVP to Mr. B. After 5 minutes the diazepam appears to have had no effect on Mr. B, and Dr. T instructs Nurse J to administer hydromorphone 2mg IVP at 4:15 pm. After 5 minutes, Dr. T was not satisfied with the level of sedation of Mr. B and instructs Nurse J to administer another 2 mg of hydromorphone IVP and an additional 5 mg of diazepam IVP. Why the incidence happened The physician’s goal for the patient was to achieve a skeletal muscle relaxation from diazepam which aid in the manual manipulation, relocation, and alignment. The condition of the patient did not change and was transferred to a tertiary facility advanced care. Seven days later, the receiving hospital informed the rural hospital that EEG’s had determined brain death in Mr. B. and the patient subsequently died. Measures to Prevent Reoccurrence of the Incidence The hospital where Mr. B. was originally seen and treated had a moderate sedation policy that required the patient to remain on continuous B/P, ECG, and pulse oximeter throughout the procedure until the patient meets specific discharge criteria. Therefore all the medical practitioners working within the hospital must first complete sedation module to ensure that similar incidence does not occur in future. Performance Improvement Plan Step 1: Document Performance Issues The first step in the improvement plan process is for the nursing supervisor to document the areas of the performance of the employee that require improvement. In the documentation of the main performance issues, the nursing supervisor needs to be objective, specific, factual, and provide facts and examples for further clarification of severity of the scenario.
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Step 2: Development of an Action Plan Secondly, the nursing supervisor should establish a provisional action plan for improvement. This may be adjusted depending on the employee feedback in the meeting. However, a collaborative process can help to identify areas of misunderstanding or confusion on the part of the employee and can encourage employee’s ownership of the issue.
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