The team summarizes the happenings in the order they occurred by a simple

The team summarizes the happenings in the order they

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The final step is writing a summary of the whole event. The team summarizes the happenings in the order they occurred by a simple diagram like a flow chart. The summary is then presented to the key players who will help in improvements. Application of the RCA process in our case study. Identification of what happened. Mr. B arrives in hospital at 3:30 p.m. complaining of leg and hip pain. He is admitted with vital signs of B.P 120/80, HR-88,T-98.6,R-32 and weighs 175 pounds. His rate pain was at 10 out of 10.Nurse J examines Mr. B’s medical history snd gives the findings to the Dr. T. After Dr. T examining Mr. B, he gives Nurse J. instructions on administering sedative on Mr. B. He is given four dozes of two different sedatives within a span of fifteen minutes. At 4:25 p.m. he is sedated and successful reduction of his hip takes place. At 4:30 Nurse J leaves to attend to another patient and leaves Mr. B in a stable condition. At 4.35 his B/P is at 110/62 and oxygen saturation is at 92% under no supplemental oxygen or respiration monitoring. His oxygen alarm is heard and it reads “low saturation”. The LPN comes and resets the alarm and repeats the B/P reading. At 4:35 Nurse J is called by son and finds Mr. B not breathing. STAT code is called and resuscitative efforts are made on him. After thirty minutes, his B/P stabilizes but he is now dependent on the ventilator. Mr. B is then airlifted to a tertiary facility where he is diagnosed with brain death.7 days later, he passes on after life support machine being removed. What should have happened? Mr. B should have been given special attention throughout. He should have been put under supplemental oxygen and under respiration monitoring. A Nurse should have been with him throughout. When the LPN came to check on him when the oxygen alarm rang, he should have dealt with it as an emergency case.
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Running Head: RCA AND FMEA 4 Determining the causes of the event. There was less staff that day and patients were many. The
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