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Crihanna SmithWGU C489Task 2
A.Root Cause AnalysisA 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 andventricular 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 werea 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 a20 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.