ROOT CAUSE ANALYSIS 4 performed the examination following the past medical

Root cause analysis 4 performed the examination

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ROOT CAUSE ANALYSIS 4 performed the examination following the past medical history that was presented to him by the nurses, and he prescribed and requested the nurses to give the patient hydromorphone 2mg IVP and diazepam 5mg IVP after thefive minutes. The dose was repeated after another five minutes when Mr. B seemed not to respond to the first dose to enhance sedation. The doctor prescribed the above medication to help in sedating the patient, thus enabling them to perform a hip reduction procedure. After the administration of the first dose, Mr. B seemed not to be sedated; therefore, the doctor requested the nurse to administer another dose of the same medication. The information from the paramedics concerning the patient with respiratory distress made Nurse J busy. Nurse J became more involved when the patient arrived at the emergency department. The problem arose because of the administration of excess doses and failure to put the patient on ECG as recommended by the hospital guidelines. Besides, the LPN nurses did not make correct reporting of the oxygen saturation of MR. B after the alarm went on. What should have been done Nurse J and Dr. B should have taken the proper past medical history to identify all the medication that the patient was currently on and the implication on the drug that was to be administered. The identification of oxycodone as the current medication of Mr. B, the doctor could not have increased the dose of hydromorphone. Besides, working as a team, the doctor and the nurses could have agreed to use another option of medication rather than hydromorphone because of its adverse effects. Determining the cause
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ROOT CAUSE ANALYSIS 5 The death of Mr. B was caused by drug overdose, lack of adequate monitoring of the patient primarily with the use of ECG as indicated by the hospital protocols and guidelines and poor communication made by LPN because she reported wrong oxygen saturation of the patient. List of recommended actions All the doctors and the nurses are to undertake a short training offered in the hospital concerning the use of sedatives and the management of patients on sedatives. Policies on the use of cognitive aids and book aids to be used by all health care providers. Proposed process improvement plan Discussion of application of Lewin’s change theory Identification of the change and team selection The nurses and physicians will be involved in conducting the change (Nursing Theories, 2017). According to the case scenario, proper patient assessment is at stake, and therefore, the evaluation of the patients by the health care providers should be changed. Gathering of data regarding the process to be changed The knowledge of the existing protocols and guidelines concerning the use of sedative needs to be reviewed and make any necessary changes.
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  • Fall '19
  • Jane Smith

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