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Running head: ORGANIZATIONAL SYSTEMS AND LEADERSHIP1Sarah Arndt5-9-18WGU C489Task 2
ORGANIZATIONAL SYSTEMS AND LEADERSHIP2A.Root cause analysisA root cause analysis (RCA) is an approach commonly used in healthcare to get a better understanding of why errors and accidents occur. The RCA asks three very important questions, which include, what happened, why it happened, and what can be done to prevent it from happening again. (IHI, 2014) It highly considers causative factors, errors and hazards that lead to a sentinel event. RCA is not used to place blame on anyone but rather to look at the processes needed to improve the system. In this scenario a patient’s death was caused, so this facility needs to take a team approach to assure that these preventable circumstances don’t happen again.The first step in RCA is to form a team, that would have some or of interest or knowledge in that scenario. The second step is to discover what happened. In the caseof Mr. B presented in this task, a patient was over sedated causing the patient to have respiratory distress and later dying. There were obvious preventable causes and errorsthat occurred in the emergency department that led to this sentinel event. The hospitalhas a conscious sedation policy that is supposed to be set forth for every patient receiving this sedation. he policy requires that all patients are to be on continuous blood pressure, ECG and pulse oximeter monitoring throughout the procedure and when the procedure is completed but it was not done throughout the procedure in this case with Mr. B. Once the procedure was completed it stated that continuous blood pressure and pulse oximeter monitoring was being done, but the ECG was not. The patient was then left in the room with family after the procedure was completed whilenurse J. went to attend to another patients. While on the monitoring, the low O2 alarms off, the LPN comes to the room to check on the patient and resets the alarm
ORGANIZATIONAL SYSTEMS AND LEADERSHIP3and repeats the BP. The oxygen levels was never addressed, no supplemental oxygen was put into place at this time, nor was the RN informed of the situation. A respiratory therapist was in the building but was also never notified of Mr. Bs situation. The conscious sedation policy mentions that all staff, including physicians that perform the conscious sedation procedure must first complete the sedation training, which includes the appropriate drug selections and dose ranges. It was not evident that Dr. T had completed this moderate sedation training. The medications given to the patient, hydromorphone and diazepam were given in to high of doses without proper timing between doses causing Mr. B. respiratory distress. There were contributing factors, and/or errors in this scenario causing this sentinel event to occur.