96%(78)75 out of 78 people found this document helpful
This preview shows page 3 - 6 out of 11 pages.
After 30 minutes of CPR, medication administration, defibrillating and placing patient on a vent, he is back in normal sinus rhythm. He is unable to breathe without the vent, so they must transport him to a different hospital as this is a small rural hospital and patient now needs a higher level of care. Patient is flownto a different hospital to where he is later pronounced brain dead. He was then taken off of life support and died. The next step is to review what could have happened or should have happened. You can use hospital policies and procedures to determine if the situation could have come outdifferently if they had followed the policies and procedures for the hospital. Also finding
out what the best and safe practices for the hospital would be beneficial such as interviewing the director. (IHI, 2018). It simply states in the scenario that policy requires that the patient remains on continuous B/P, ECG, and pulse oximeter throughout the procedure and until the patientmeets specific discharge criteria which is when the patient is stable, awake, no N/V, can void and VSS. The patient was not on an ECG machine. They must also complete a training module for hospital sedation per the hospital. This training module went over the medications and acceptable dose ranges. Additional hospital staff were on back up that day but were not called in to help when it got busy. Had they had more staff, they could have caught the respiratory distress earlier especially if a nurse stayed with the patient until he woke up. The nurse that would stay with Mr. B would be the nurse that completed the sedation module and this nurse also had her ACLS. The LPN should not have come in to check the alarm and reset it. Something should have been done when the first alarm sounded and his O2 was 85%.Determining the causes that lead up to this event and what contributed to it. Here the team identifies what were the direct causes of the event and why. Was it due to staffing issues or was it due to not following a policy and procedure? Here it should be clearly identified. Diagrams are good to use in this step especially a cause and effect diagram. It can help point out the factors a little easier. There were only two nurses staffed in that ED with staff on backup. One nurse was an LPN and one was an RN. They should have called in the back up crew to assist with the emergencies and also whenthe waiting area started getting busy. That is an unsafe staff to patient ratio. They also did not follow the policy for the sedation policy. The LPN should have also
communicated to the RN that his O2 was 85% when the first alarm had sounded. Therefore, there is a lack of communication as well.Develop a causal statement. This will link the cause to its effects and then back tothe main event that brought about the RCA to begin with (IHI, 2018). Here, the facts would be stated that contributed to the bad outcome of the patient as well as staff (IHI, 2018). This is not a step to point out blame it is just to simply state a cause and effect and what the outcome of the event would be. The nurse did not question the doctor about the