The RN finds the patient to be in ventricular fibrillation with a critically low blood pressure and oxygen saturation. A code is called, and CPR begins. Staff successfully resuscitates the patient, although he is ventilator dependent, and the patient is transferred to another facility. At the other facility, the patient is found to be brain dead and taken off life support, resulting in death. In step two and three, we identify the steps that should have been taken to avoid the patient’s death as well as the steps that actually did occur. The rural hospital has a policy in place that requires patients to be on continuous blood pressure, cardiac, and pulse oximeter monitoring throughout the procedure and until the patient discharge criteria, such as being fully awake and alert and stable vital signs. Had the patient been placed on these monitoring machines during the procedure, the RN might have noticed a change in status, especially since these medications take some time to take effect. Furthermore, there was additional staff available to be called in to work. With the influx
4 Running Head: RCA and FMEA of patients after the procedure, the RN didn’t realize the change in the patient’s declining status. Additional staff would have allowed the RN to focus more on the patient. Lastly, the LPN should have notified the RN about the alarms going off on the patient regarding the worsening vital signs. In step four, we create causal statements. In the scenario, the patient wasn’t placed on continuous monitoring devices at the appropriate time, which led to the patient’s change in status going unnoticed, ultimately causing brain death. Additionally, there was limited staff available to treat and see patients in the ER which also lead to the patient’s status changes going unnoticed, leading to patient death. Lastly, alarms going off alerting staff to the patient’s declining vital signs were silenced by staff without any further action which led to the RN going unnotified regarding the patient’s alarms and eventually the patient’s death. Step five requires brainstorming to develop steps to be taken in the future to prevent a similar sentinel event from occurring. These steps could include a checklist for staff to fill out when administering sedating medications, reminding staff to place patients on monitoring devices. Special stickers could also be placed on the medications themselves stating that patients must be on monitoring devices when administering this medication, as an additional reminder to staff. Further training for LPNs and RNs could
You've reached the end of your free preview.
Want to read all 10 pages?
- Spring '16