Also Mr Bs O2 saturation alarm was reset by the LPN even though it read 85 She

Also mr bs o2 saturation alarm was reset by the lpn

This preview shows page 3 - 5 out of 8 pages.

LPN even though it read 85%. She did not report this to the RN or doctor so no action was taken. Contributing factors that led to this sentinel event include poor staffing to closely monitor Mr. B and cover the incoming emergencies even though there was back up staff available. A knowledge deficit of Diazepam and Hydromorphone on the doctors’ part. The RN should have caught this error as well. Mr. B’s history of narcotic usage was never factored in when administering the Hydromorphone and Diazepam.B. Proposed PlanThe first part of my process improvement plan would be to have mandatory conscious sedationtraining for physicians and nurses hospital wide. Patients requiring conscious sedation may only be cared for by staff who have successfully completed this training and are ACLS certified. LPN’s must also attend the training and will receive extra training on proper communication. A checklist must be provided for the nurse caring for the patient to ensure hospital protocol is being followed including continuous B/P, pulse oximeter, and ECG monitoring. Continuing education will be provided to staff nurses to decrease the likelihood of this happening again. Also, educating nurses when to call for backup staff. B1. Lewin’s Change Theory was developed by Kurt Lewin, which is defined as “a dynamic balance of forces working in opposing directions” (Nursing Theory, n.d.). Unfreezing, change, and refreezing are the three stages of this theory. The unfreezing process makes it possible for
Background image
C489 TASK 24people to let go of old pattern that are counterproductive. In this scenario, unfreezing would be the mandatory conscious sedation training doctors and nurses must attend. Also, better communication between the LPN’s and the RN’s. The next stage is change, which is also called“moving to a new level” (Nursing Theory, n.d.). The “change” in this scenario would be providing nursing staff check off lists that contained hospital protocol when caring for a conscious sedated patient. Making sure staffing ratios are sufficient and empowering the nursesto call for backup when needed. Staying on top of ACLS requirements for all nurses caring for conscious sedated patients would also be a part of the change process. The final step in Lewin’sChange Theory is refreezing, which is establishing change as the new habit. During this process, continuing education will be provided to staff nurses. New hires will receive proper education on this matter and within a certain time period of being hired. Staff should feel empowered to make suggestions for improvements and voice concerns they may have as well.
Background image
Image of page 5

You've reached the end of your free preview.

Want to read all 8 pages?

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture