67%(3)2 out of 3 people found this document helpful
This preview shows page 1 - 5 out of 10 pages.
Running head: Organizational Systems Task 21Organizational Systems and Quality LeadershipSAT Task 2 RCA/FMEALori A. Di BettaWestern Governors UniversityUpdated: 2/1/19
Running head: Organizational Systems Task 22Organizational Systems and Quality Leadership SAT Task 2A. Root Cause AnalysisThe general idea of conducting a root cause analysis is to learn from errors by using a systematic approach to figure out the causes of an adverse event, and identifying defects in the system that can be fixed to prevent the error from happening again. A1. RCA StepsStep 1: Identify what happenedStep 2: Determine what should have happened.Step 3: Determine causes (“ask why five times”).Step 4: Develop causal statements.Step 5: Generate a list of actions to prevent the recurrence of the event.Step 6: Share the findings.A2. Causative and Contributing FactorsStep 1: What HappenedPresentation:67 yo male with hx of impaired glucose intolerance, prostate cancer, hypercholesteremia and hyperlipidemia, chronic back pain, opioid (oxycodone) use, presents to ED complaining of severe pain in L leg and hip. Had a fall after tripping over dog. BP 120/80, HR 88, RR 32On Admission:Admit to regular ED from Triage. L leg appears shortened with edema in the calf, ecchymotic and limited ROM. ED Course:1605 5 mg IV Diazepam. Not effective.Updated: 2/1/19
Running head: Organizational Systems Task 231615 2 mg IV Hydromorphone. Not effective1620 5 mg IV Diazepam, 2 mg Hydromorphone1625 Pt sedated, Hip reduction takes place. 1630 Pt resting comfortably. Pt placed on automatic BP and pulse oximetry to go off every 5 minutes.1635 BP 110/62, O92%. ECG and respirations not monitored. No supplemental oxygen ₂given.1640 Ofound to be 85% after oximeter alarms. Alarm reset by LPN₂1643 Pt BP 58/30, Osaturation 79%, no respirations, no palpable pulse₂Code is called. Resuscitation begins after code team arrives. Pt in Vfib. RN begins CPR, Pt intubated. Defibrillated, given reversal agents, IV fluids and vasopressors. After 30 minutes of intervention NSR regained, pulse evident, BP 110/70. Pupils dilated and fixed, pt dependent on vent. No spontaneous movements, no response to noxious stimuli. Pt transported to tertiary facility for advanced care, found to be brain dead, removed fromlife support. Step 2: What Should Have HappenedAdditional, available staff should have been called in when census increasedBP and pulse ox should have been on continuouslyECG and Respirations should have been monitoredLow Osaturation should have been assessed and addressed ₂Clinical status should have been reassessed following clinical change (drop in O₂saturation)Updated: 2/1/19
Running head: Organizational Systems Task 24Notification of RN should have happened after pulse oximetry alarm was resetCPR should have begun prior to arrival of code team All employees working in ED should have ACLS (inferred that LPN did not have ACLS)Step 3: CausesStaffing policies were not in place to address census issues, or policies were not followed.