Crihanna Smith
WGU C489
Task 2
A.
Root Cause Analysis
A root cause analysis is a systematic process for identifying “root causes” of problems or
events and an approach for responding to them. [Ris17]
The final outcome for this scenario
is that Mr. B died an unnecessary death. Mr B. died due to the lack of oxygen to the brain and
ventricular fibrillation. Upon initial assessment of Mr. B. His vital signs were within normal
limits. His oxygen levels at that time were good enough that he didn’t require supplemental
oxygen. Mr. B was given an increased amount of sedation meds to block his pain which were
a direct effect for decreased O2 levels and hypotension. Being in a very busy emergency
room unexpected things happened and he was not given the proper attention for his current
situation. In this scenario there were several causative agents for his death.
Starting with the
initial procedure The Dr prescribed 10mg of Diazepam and 4mg of Hydromorphone
within a
20 minute period to be able to relax Mr. B so he can manipulate his hip. Dr. T did not allow
enough time for the medication to take effect which caused any increase amount of sedation
drugs to be given. The nurse nor the Dr. followed the sedation protocol until Mr. B met
discharge criteria. Protocol for this facility was for the patient to be on continuous ECG, O2
and blood pressure monitoring. Staffing at this time was also a concern in this scenario.
While Mr. B. was recovering 2 patients were waiting to be discharged and an emergent
patient was in transit plus the waiting room was filling up. At this point additional staff
should have been called in. There was no communication to each other about needing help
and calling in additional staff.
The LPN on staff didn’t communicate to the RN that Mr. B.’s
O2 monitor was alarming at 85% saturation. There was also a knowledge deficit when it
came to Dr.T prescribing the pain and sedation medication to Mr. B and not knowing the half
life of these meds. Maybe the Dr should have used different medications to sedate so that the
half life is shorter and won’t cause hypotension. Another Knowledge deficit was when the
LPN came in and turned off the alarm and didn’t put Mr. B on supplemental oxygen when
O2 was at 85%.
I have identified the causative and contributing factors in this scenario as
well as errors which were hazardous. An error is an error because it can be backed by a
protocol, rule or evidence based practice. The errors in this scenario were that Mr. B was not
put on continuous ECG, The LPN didn’t put Mr. B on supplemental oxygen when O2 was
alarming at 85% saturation. The LNP also didn’t communicate to the RN about the O2
alarming. The other causative agents are hazardous. With no dedicated nurse for Mr. B is a
hazard because there is no rule for it and it’s not a requirement for the sedation protocol. The
amount of staff that they had that day was also a hazard. One Dr, One Nurse and One LPN
are not enough staff for a day like this. The last hazard was no communication between the
staffing.
