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overmedication, and the lack of continuous ECG monitoring resulted in failure by medical staff to recognize Mr. B’s conversion to a lethal arrhythmia in time to initiate successful ACLS protocols. Tying into the absence of crucial monitoring was the failure of the LPN to recognize and act on the onset of respiratory failure. In the scenario, Mr. B’s low sat alarm activated, reading a pulse ox of 85% on room air. In response to this, the LPN chose to silence the alarm and recycle the blood pressure, when the proper course of action would have been to administer supplemental oxygen and immediately notify Nurse J and Dr. T so that reversal agents and respiratory support could have been given. Also, the scenario describes Mr. B’s son being escorted to the waiting room between the time that the STAT code is called and the time that the code team arrives to begin resuscitation efforts.If there actually was that much of a lag, the valuable time was certainly lost. CPR should have been started at the same time that the code was called, with the unit secretary or other non-essential personnel being delegated to escort Mr. B’s son to the waiting room. These are all factors which directly led to the sentinel event, with the root cause being, in this author’s
Task 3 4opinion, failure to properly monitor Mr. B’s vital signs post procedure, failure to recognize the onset of respiratory failure, secondary to respiratory depression post conscious sedation, and failure to provide respiratory support and reversal agents.One particular process improvement plan that could be utilized to decrease the likelihood of a reoccurrence of the sentinel event would be to conduct periodic staff training to reinforce proper conscious sedation procedure protocols and the need for them to be conducted properly every time. Additionally, department staffing should be addressed, particularly the need for greater staffing numbers in the ER, as once a high acuity patient arrived via EMS, all department nursingand medical staff members became preoccupied with caring for that patient. This caused a critical lapse in care for Mr. B, resulting in his respiratory failure, cardiac arrest, and eventual death. The requirement for proper post conscious sedation vital sign monitoring and oxygen administration should also be reviewed with staff and strictly enforced as well.A change theory which could be utilized to implement the aforementioned improvement plan is Lewin’s change theory. The theory’s three concepts are unfreeze, change, and refreeze. To understand how this change theory can be utilized, one must understand the components of the theory. Unfreezing is a process that seeks to discover methods that allow workers to dismiss